SAMPLE REPORT

Private & Confidential

Ref. No.: 2011/11/46/B Date: 08/08/2023

This report is issued without prejudice, in respect of cause, nature and extent of loss/damag and subject to the terms
and conditions of the Insurance Policy and Insurer admitting liability

Subject : Claim for Vehicle Registration No. HR36AK8339, Accident Date : 17/07/2023

Insured : CHARANVEER SINGH

Policy No. : 39070031233800000389
Insurance Period : 22/04/2023 To 21/04/2024
Claim No. : 3907003123
Appt. Officer : PRADEEP

Policy No. : 39070031233800000389

Insurance Period : 22/04/2023 To 21/04/2024
Insurance Particulars
Insurer : National Insurance Co. Ltd.
D.O.-X, Scope Minar Core-3, IInd Floor, Laxmi Nagar,
District Center, Delhi, Delhi 110092
Insured : CHARANVEER SINGH
A-46/6, GALI NO.1 JAFRABAD M-A-46/6, GALI NO.1
JAFRABAD
Policy No./Cover Note No. : 39070031233800000389
Period of Policy : 22/04/2023 To 21/04/2024
IDV : Rs. 537912.00
Vehicle Particulars RC: YES
Registration No. : HR36AK8339
Registered Owner : CHARANVEER SINGH
Date of Registration : 03/06/2021
Chasis No. : 4200618 Physically Verified :Yes
Engine No. : 13907910 Physically Verified :Yes
Engine Capacity : 1498 CC
Vehicle Make : HONDA
Vehicle Model : AMAZE
Vehicle Variant : SEDAN
Type of Body : SEDAN
Colour of Vehicle : LUNAR SILVER
Class of Vehicle : FOUR WHEELER
Seating Capacity : 5
Odometer Reading : 52751 Kms
Fuel used as per RC : Diesel
Tax paid upto : OTT

F-6, Friends Apartments, 49 IP. Extension, Delhi-110092

Email ID: info@paramountservices.co.in, Mobile No. +91 98914 55847
Driver Particulars DL: YES
Name of the Driver : CHARANVEER SINGH
Driver DOB : 14/10/1996
Driver Address : VILL KHAKHUNDA BULANDSHAHR

Relation with the insured : OWNER

Driving License Number : UP1320150022174
Valid from : 2015-07-30 Upto 2035-07-29
Issuing Authority : BULANDSHAHR
Type of License : MCWG, LMV
Type of Vehicle Allowed To Drive : MCWG, LMV
Accident Particulars
Date and Time of Accident : 17/07/2023
Place of Accident : DHARUHERA
Place of Survey : ASHOK VIHAR, PHASE-3, HARYANA
Date of request for Survey : 19/07/2023
Date and Time of Survey : 20/07/2023 03:50 AM
Particulars of Police Report
Has accident been report to Police : Yes
Has Panchnama been carried out : Yes
Particulars of Third Party Injury / : No
Loss
Injury to Driver / Occupant ( If any ) : No

Cause and Nature of Accident

As, per claim form
Original Estimate
Dated 19/07/2023 for Rs.6271.00 was submitted by KUBER AUTOMOTIVE

(Issued without Prejudice)

For PARAMOUNT SERVICES

F-6, Friends Apartments, 49 IP. Extension, Delhi-110092

Email ID: info@paramountservices.co.in, Mobile No. +91 98914 55847
 Ref. No.: 32 HR36AK8339 Page 3 of 4

LOSS ASSESSMENT

In respect of Vehicle Registration No. HR36AK8339, Accident Date : 17/07/2023

(Annexure 'A' attached to Survey Report No. 32)

ASSESSMENT OF LOSS (PARTS)

S. Description of Remark IGST % Estimated Assessed Parts Amount

No Parts (Amt in Rs) Metal Rub/Plast Glass Fibre

1 Windscreen 18.00 5119.00 - - 4500.00 -

Total 5119.00 0.00 0.00 4500.00 0.00

Add IGST @18% 921.42 0.00 0.00 810.00 0.00

Total 6040.42 0.00 0.00 5310.00 0.00

@ 0.00% on Metal, 0.00% on
Less Dep Rub/Plast,0.00% on Glass Parts, 0.00% on 0.00 0.00 0.00 0.00
Fibre Parts
Total 0.00 0.00 5310.00 0.00

Total 5310.00

LABOUR CHARGES

sr. no Description of Parts Remark Estimated O/F & Denting Painting

(Amt in Rs) (Amt in Rs) (Amt in Rs)
1 Windscreen 0.00 0.00 500.00
Total 0.00 500.00 0.00
Add IGST @18.00% 0.00 90.00 0.00
Total 0.00 590.00 0.00
Less 0.00% on 25.00% of Painting Labour 0.00 0.00
Total 0.00
Net Labour Amount (O/F & D/B + Painting Labour) 590.00

Summary of Estimate and Assessment of Loss

O/F & Denting Painting

(Amt in Rs) (Amt in Rs)
Total Cost of Parts 6040.42
Parts (Metal) 0.00
Parts (Rub/Plast) 0.00
Parts (Glass) 5310.00
6040.42 5310.00
6040.42 5310.00
Net Labour Charges 0.00 590.00
TOTAL 6040.42 5900.00
Compulsory Deductable (-) 1000.00
Less Salvage (-) 150.00
TOTAL 6040.42 4750.00
Net Liability on Repair Basis 4750.00
PARTS TAX SUMMARY

Sr. No. Tax % Depreciated Amt CGST SGST IGST Amount

1 18.00 0.00 0.00 0.00 810.00 810.00

Grand Total 0.00 0.00 0.00 810.00 810.00

LABOUR TAX SUMMARY

Sr. No. Tax % Depreciated Amt CGST SGST IGST Amount

1 18.00 500.00 0.00 0.00 90.00 590.00

Grand Total 500.00 0.00 0.00 90.00 590.00

PAINTING LABOUR TAX SUMMARY

Sr. No. Tax % Depreciated Amt CGST SGST IGST Amount

1 18.00 0.00 0.00 0.00 0.00 0.00

Grand Total 0.00 0.00 0.00 0.00 0.00

Net Liability
Based On Details Provided Above, The Justified Liability Under The Subject Policy Of Insurance Works
Out To Rs.4750.00 (Rupees Four Thousand Seven Hundred Fifty )subject to terms & conditions of
Insurance policy & attachment of liability of Insurer.

(Issued without Prejudice)

For PARAMOUNT SERVICES

F-6, Friends Apartments, 49 IP. Extension, Delhi-110092

Email ID: info@paramountservices.co.in, Mobile No. +91 98914 55847