Complaint No Complaint Date Service Centre Customer Name Mobile No

GUJ2208190046 22-Aug-19 CE - UNIQUE SERVICES Mr. JAGANNATHROUT 9879604659

Model No Set Sr. No Customer Invoice No Customer Invoice Date
LED TV 32T8361HD 00311B874289240 7328 10/17/2017
Complaint Part to be Replace Part Code Call Charges - In Wty
No Picture LED TV 32T8361HD L32T8361HD 700
Estimated Part Cost (ASC Billing Price) Total Cost Date of Intimation Date of Approval
8500 9200 8/24/2019
Remarks - if Any
region state SF Name Jobsheet NCall Logge TAT(in min.Call Agein Call StatusPending R Tele Caller

WEST GUJARAT CE - UNIQ GUJ22081 22/08/202 5:37:33 2 DAYS Pending foPending SeCESUPPOR
Dealer Na Dealer Ph Allot Date Allot Time Appointment Date Appointment Time Customer

NA NA 8/22/2019 5:37:33 8/23/2019 05.00pm to 6.00PM Mr. JAGAN

Customer Address

Alok staff quarters B7 A Room no.003 opposite-Basera complex Amli Tirupti Balaji Temple Balaji temple road. Silvassa
city locality Pin Code Registered Contact No. Mobile No. TelephoneProduct CaPRODUCT

VALSAD SILVASSA 396230 9879604659 7984586006 NA MMX LED LED TV 3

Model Name Serial No. Date of purchase Warranty SCall Cente Symptom fault Defect Call Type

L32T8361HD 00311B874 10/17/2017 Extended NA NO PICTURNO PICTURNO PICTURRepair

Engineer'sEngineer' Part Code Part DescriP.O. No. Purchase OInvoice NoInvoice DaInvoice Re Order Stat
7000018439 PANEL - 3
panel probJignesh NA NA NA NA NA NA
Service CoLocal/Up-CRepair WarService O Customer Engineer AService Outcome

NA Local OUT-OF-WNA INDIVIDUAL CUSTOMNA

 Customer
SCHNO Registration Date Address City State PinCode Model Category
Name

Alok staff
quarters B7 A
Room no.003
opposite-Basera
complex Amli
Tirupti Balaji
Temple Balaji
SCH17-17- JAGANNA 32T8361H
12/13/2017 0:00 temple road. GUJARAT VALSAD 396235 32
12-308032 TH ROUT D
Silvassa Dadra
& Nagar Haveli
396230 Silvassa
Dadra & Nagar
Haveli, DADRA
& NAGAR
HAVELI
 Insurance
DealerNa
SerialNo DOP Company Warrenty
me
Name

HDFC 2017-10-17
00311B874289240 10/17/2017 NA
ERGO
 HDFC ERGO General Insurance Company

EXTENDED WARRANTY INSURANCE POLICY- CLAIM FORM

"ISSUANCE OF THIS FORM IS NOT A PROOF OF ADMISSIBILITY OF LIABILITY”

Important Notice
1. Please read this Claim Form fully before answering the questions
2. All questions must be answered as fully as possible. Please use additional sheets if necessary
and copies of relevant documentation should be attached.
3. Please send the completed claim form, within 45 days, to the Administrator.

DETAILS OF THE INSURED

(a) Policy Number: SCH17-17-12-308032

(b) Name of the Insured:
JAGANNATH ROUT
(c) Address of the Insu Alok staff quarters B7 A Room no.003 opposite-Basera complex Amli Tirupti Balaji Temple Balaji temple ro
SILVASSA
Pincode 396230
(d) Telephone No.: 9879604659 7984586006

(e) Email id:

F DAMAGED PROPERTY

(a) Description of Item / Property Purchased

(i) Type of Property: LED TV

(ii) Manufacturer: Micromax Informatics LTD
(iii) Make & Model No: LED TV 32T8361HD
(iv) Batch & Serial No. 00311B874289240
(v) Product Code (if any): L32T8361HD
(vi) Engine No.:
(vii) Chassis No.:
(b) Date of Purchase: 10/17/2017

(c) Place of Purchase: Vapi

(d) Purchase Price: Rs 12498

DETAIL DESCRIPTION OF ISSUE

(a) Description of Problem No Picture
` It is Normal failure…………….not electronic breakdown or manufacturing defect
History of the affected item – There is no previous Fault History of the affected item

HDFC ERGO GENERAL INSURANCE COMPANY LIMITED (Hereinafter, called as the Company), 6th Floor, Leela Business
Park, Andheri Kurla Road, Andheri East, Mumbai – 400059.
 HDFC ERGO General Insurance Company

(b) Date of Problem Occurred (DD/MM/YY): 30-Dec-99

(c) Original Warranty Period: (DD/MM/YY) 17-Oct-17 To 30/08/2018

(d) Details of previous claims (if any)

Date of Item/s Amount

Part Name Part Number Company
Claim Claimed Claimed
Micromax
22-Nov-2019
1 LED TV 32T8361HD L32T8361HD Informatics LTD 9200

(e) Estimate Quantum of Loss: 9200

LIST OF DOCUMENTS REQUIRED

 Original receipt of purchase
 Completed and signed claim form
 Copy of Manufacturer’s warranty of the Insured product
 Any other documents which could be construed as material information to the case.
DECLARATION
I/We (print name in full)
the named Insured or on behalf of the named Insured hereby certifies that the information provided on this form and otherwise in support of this
claim is complete and accurate to the best of our knowledge and belief. In the event of any false or misleading statement in the making of this claim,
coverage can be void, payment of this claim can be denied and any claim payments made in error recovered. The undersigned agrees to refund the amount of
any payments that should not have been made.

Date
11/22/2019
Please attach a separate sheet wherever required for giving the details.
Note :
Send Notice of Claims To:

The Manager
Claims Department
HDFC ERGO General Insurance Co. Ltd.
6th Floor, Leela Busines Park, Andheri Kurla Road, Andheri East, Mumbai-400059

Toll Free Helpline: 1800 2 700 700

Such notice shall be effective on the date of receipt by the Company at such address.

HDFC ERGO GENERAL INSURANCE COMPANY LIMITED (Hereinafter, called as the Company), 6th Floor, Leela Business
Park, Andheri Kurla Road, Andheri East, Mumbai – 400059.
i temple road. Silvassa

la Business
Amount
aimed

9200

port of this
aim,
he amount of
la Business