LIFE INSURANCE CORPORATION OF INDIA

SOUTH CENTRAL ZONE: HYDERABAD Form 3018

Ref: Mktg/ Date : 07.06.2022

APPLICATION FOR SANCTION OF MAJOR REPAIRS AND REPLACEMENT

1. Name of the Officer : P. MADHUSUDANA RAO

2. Designation & place of posting : D.G.M. (Life) in IRDAI, Hyd in SDM cadre

3. Particulars of the car :

a) Make & Regn. Of the car : Hyundai Verna White

b) Date of entry into the scheme : 27.06.2019

c) Date of purchase as new car : 27.06.2019

4. Details of the proposed repairs or replacements: BILL ENCLOSED

a) Description of the proposed repairs/replacements :

b) Reason for the proposed repairs / replacements :

c) Names of the parts to be replaced :

d) Date when the concerned repairs / replacements were last made: FIRST TIME REPAIRS

UNDERTKEN SINCE THE CAR WAS PURCHASED

e) Milometer reading on that date:

f) Name & address of the garage consulted and their repairs : (letter and quotation from

the garage should be enclosed). BHARAT MOTOCORP PVT LTD, NANAKRAMGUDA, HYD

g) Name & address of the garage where the repairs / replacements are proposed to be

carried out if it is different from that mentioned in (f) above. NOT APPLICABLE

h) Details of cost of proposed repairs/replacements BILL ENCLOSED

Item No. Cos Repairs or Total

As per Name of the parts of parts Labour Charges

Schedule Rs. Ps Rs. Ps. Rs. Ps.

 Bill No. B 202003609 dt 19.05.22 of Bharat Motocorp Pvt Ltd for RS 15,351 enclosed.

For replacement of tyre and allied works.

i) Advance, if any, required to be paid to the garage: NIL

5. Please state whether the cost of repairs / replacements is to be met by the Insurance
Company. If so, give details of the claims made etc.

NO

6. Amount of advance, if any, applied for by the officer: Rs NIL

Date: 07.06.2022

Place: HYDERABAD SIGNATURE OF THE OFFICER.

Note: Reimbursement under Part-C is admissible only in items listed in Schedule-I while giving details
of the proposed repairs and replacements under item 4(b) indication should be given of the item in
Schedule-I which covers the proposed repairs and replacements.