UBL Insurers Limited

ver1.3

( CLAIM INTIMATION PERFORMA )

Un-Posted
Branch : City Branch Insurance Type : Direct (UIL 100%)
Department : Motor Printing Date : 10/11/2020 11:48:23AM

Claim No. : 2020004VPCDI00118 Claim Status : Valid Claim

Cause of Loss : Accident Old Claim No. :
Date of Loss : 10/11/2020 Loss Claimed : 15,000
Intimation Entry # : 1 Loss Assessed : 0
Intimation Date : 10/11/2020 Loss Adjusted : 0
Revision Date : Loss Incurred : 15,000
Deductible : 0 Premium Outs : 0

Insured : MIAN RIZWAN RAUF

Address : HOUSE NO. 5, KHAYABAN-E-SAADI, PHASE-VII, D.H.A., KARACHI.
Claim Description :
Sr. Policy # Business Class Issue Date Comm Date Expiry Date Policy Sum Insured
1 2020004VPCDP00056 PRIVATE CAR (COMPREHENSIVE) 05/03/2020 04/03/2020 03/03/2021 2,200,000

Intimation Remarks : CONTACT 0300-7067086

Item Sum Insured : 2,200,000

Item No. : 1
Make : TOYOTA COROLLA ALTIS CVTI GRANDE Registration No. : BFH-259
Body Type : Saloon Engine No. : Q315019
Manufacturing Year : 2016 Chassis No. : 7014082
Keeper Name :

Loss Share Distribution --Re-insurance

Base Document No./ Loss Amount Loss Amount Treaty PRCL Local Foreign Excess Company
Sr. Itm No./Item Desc (100%) (Our Share) Amount Amount Fac Fac Amount Net Loss

1 2020004VPCDP00056 15,000 15,000 0 0 0 0 0 15,000

Grand Total 15,000 15,000 0 0 0 0 0 15,000

Surveyor Detail:
Date of Report Surveyor Fee
Sr. Surveyor Appointment Report No. Date Bill No. Bill Date Other Charges

1 AL-MEEZAN ASSOCIATES (PVT) LIMITED 10/11/2020 0

Grand Total 0

Advocate Detail :
Sr. Advocate Court Charges/Fee Hiring Date Fee Claimed Comments

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 UBL Insurers Limited
ver1.3

( CLAIM INTIMATION PERFORMA )

Un-Posted
Branch : City Branch Insurance Type : Direct (UIL 100%)
Department : Motor Printing Date : 10/11/2020 11:48:23AM

Claim History of Engine # and Chasis # :

Sr. Claim Policy# Inti/ Revi. Surveyor Salvage Total Cheque# Amount
Reference No. Branch Date Amount Amount Loss Cheq. Date Paid

Grand Total 0 0 0

Documents Required / Received :

Sr. Documents Receiving
Required/ Received Date
0

ASSESSMENT LABOUR PARTS DEP.

Estimate

Settled

Less Deductible

Remarks

Authorized Signature

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