No.

129255
CEYLINCO INSURANCE PLC REPORT
"Ceylinco House", 69, Janadhipathi Mawatha, Colombo 01. Hotline: 2393939

ON THE SPOT LOSS ADJUSTMENT REPORT

Date & Time of Intimations: 06/06/2022

Claim No.: CLKR00TC22000001 P

Policy No.:
KR0021TC0001726
P
Insured Name: MR.. . W.A.T.M WICKRAMAARACHCHI
Risk Location NO 47 THILINA STORS KATHTHARAGAMA GALNEWA

Sum Insured: Building Stock in Trade

B'Wall Stock Held Trust

E. Installation Furniture
Machinery Equipment
Others Others
ConditionslWarranties Deductible/Excess
Reinstatement/Indemnity Financial Interest
Date & Time of intimation: 04/06/2022 Date & Time of Survey held: 04/06/2022
Amount of Claim: Electrical fire
Cause of Loss/Damage:
Underinsurance (average):
Deprecation:
Date & Time of Loss:

Description of Loss / Damage: Power supply of the CCTV camera system (10A)

Claim Reserve: Claim Advance:

Further inspection place & date . Salvage: Deduct / Ignore / Collect

SPECIAL NOTES:
This is transferred policy from CLGL001C22000013
There can be observed the evidences of electrical fire on fuse and inductor.
Final adjustment is Rs. 6,500/= subject to policy conditions, coverage and excess.

0'

CLAIM ADJUSTMENT SUMMARY:

08/06/2022 Akila Wickramanayake

DATE NAME SIGNATURE OF LOSS ADJUSTER
(RUBBER STAMP)
DECLARATION (TO BE FILLED BY THE INSURED)
(1) I/We hereby confirm a representative from Ceylinco Insurance PLC. visited the location to inspect / survey & approval has been granted to repair /reinstate /
indemnify the loss, in accordance with the terms and conditions of the policy issued.

Date: ................................................ Name: .................................................. Signature: ............................................................

(With company rubber stamp)
N.I.C. No. .......................................................
(2) I am /We are in total agreement with the loss adjustment carried out at the above mentioned location. I/We also hereby expressly acknowledge having
received from Ceylinco Insurance PLC, a sum of Rs. ............................ Being the full & final settlement of my/our claim for the loss/damages

Date: ................................................ Name: .................................................. Signature: ............................................................

(With company rubber stamp)

(3) In consideration of the above settlement without producing of the Repair bills/Estimates/BOQ/Stocks record etc., we expressly undertake not to hold
Ceylinco Insurance PLC, responsible for any consequences of whatever nature which may arise as a result of setting the claim in the aforesaid manner and
further I/We undertake to submit all documents requested by Ceylinco insurance PLC..

Date: ................................................ Name: .................................................. Signature: ............................................................

(With company rubber stamp)