Sanjeev Agrawal Phones: (0761) 3566215 (Fax),email: sanjeev767@yahoo.

com, Address: 44,

B.Tech. M.I.E, C.Engg., AIII, FIISA, FIV
Narmada Road, Near, Gorakhpur Police Station., Jabalpur (M.P) Mob : 098261-
15667, 94251-52657, 94258-01467 Website-www.sanjeev767.com
SANJEEV AGRAWAL & ASSOCIATES
(Equipped with the Team & Associates of )
Insurance Risk Engineers/Surveyors/Loss Assessors / Regd. Appvd. Valuers / Engg. Consultants/Chartered Engineers
Surveyor’s Lic. No. SLA-4925. Exp.-09-08-2025, Chtrd. Engrs Regn No. M-053136/1 Valuer’s Regn No. F-16360 & F-1285

Ref. No.:23/UIIC/… Date: ....03.2023

PRIVATE & CONFIDENTIAL
WITHOUT PREJUDICE-MOTOR SPOT/FINAL SURVEY REPORT
This report is issued by me as licensed Surveyor, without prejudice, in respect of cause, nature and extent of loss/damage and subject
to the terms and conditions of the insurance policy.
1 Insurance Particulars:-
(a) Claim No. : `0209003122N062764 - Deputed through UIIC Portal
(b) Policy/Cover Note No. : `0209003122P104658336 (0% Depn. Policy)
(c) Validity : 23.08.2022 to 22.08.2023
(d) Sum Insured/IDV : Rs. 3,80,000/-
(e) Insurers/Under writers : United India Insurance Co. Ltd. TMI Tie-Up
(f) Insured's Name/ Banner : Mr. Ankit Sahu S/o Shri Tikaram Sahu
1205, Gali No. 22, Shanti Nagar, Damoh Naka, Rajeev Gandhi Ward,
(g) Insured's Address :
Jabalpur M.P. Cont. No. - 9303238717
(h) HPA with : Central Bank of India, Jabalpur
2 Vehicle’s Particulars:-
(a) Registered Owner : Mr. Ankit Sahu S/o Shri Tikaram Sahu
(b) Registered No. : MP20CH5660
(c) Date of Registration : 30.08.2018
(d) Chassis No. : MAT626184JKE43615 Also{Verified Physically}
(e) Engine No. : 105LCR02ERYW19062 Also{Verified Physically}
(f) Make/Model/Year of Mfg. : Tata Motors Ltd. / Tiago XZ 1.05 RTQ BSIV / 2018 / 1047 CC
(g) Class of Vehicle : LMV / Private/ Car / Hatch Back (Diesel Vehicle)
(h) Pre-Accident condition : Good
(i) Registered Laden Weight : NA
(j) Un-Laden Weight : 1080 Kgs.
(k) Carrying Capacity : NA
(l) Seating Capacity : 4+1
(m) Fitness Cert. No. : NA
(n) Permit No. : NA
(o) Type of Permit : NA
(p) Route / Area of Operation : NA
(q) M/V Tax Paid upto : Life time tax paid

3 Driver's Particulars:-
(a) Name of Driver & Add. : Mr. Ankit Sahu S/o Shri Tikaram Sahu R/o Jabalpur M.P.
(b) MDL No. : MP20N-2011-0317724 (DOB - 31.05.1986)
(c) Date of Issue : 06.09.2011
(d) Valid Upto : 05.09.2031 w.e.f. 06.09.2011
(e) Issuing Authority : RTO (LA) Jabalpur (M.P.)
(f) Type/Authorized to Drive : Permanent, Auth. To drive MCWGR, LMV-NT only
 Also Downloaded from MP Transport & Parivahan (Govt. of India)
(g) Badge No./Endorsements :
Website
4 Accident Particulars :-

(a) Date & Time of Accident : 03.03.2023 at about 3:30 PM

(b) Place of Accident : Near Village Sunpuri, Dindori MP

(c) Date of Allotment of Survey : 13.03.2023

(d) Date & Time of Survey/AT : 13.03.2023 onwards at Dealer's workshop, Jabalpur

(e) Date of receipt of SSR : Not Held

5 Details of Survey
(a) Spot Survey Details
(b) Police Report / Notifications
(c) TP injuries/Ppty/ Damages
(d) Details of Load Challan
(e) Occupants/Injuries etc.
(f) Verification of Documents
(g) Details of Estimate etc.
(h) Cause & Nature of accident
: Pursuant to the instructions received from UIIC Portal, the
undersigned carried out the survey of the subject vehicle at Dealer's
workshop Jabalpur, along with Insured. Details are as under:-
: Not held, however insured had arranged few photographs of the
vehicle at Spot which are furnished and enclosed.
: Matter was intimated to PS Gadasarai, Distt. Dindori on 03.03.2023
and police has duly acknowledged the insured's intimation and
entered the matter in Station Diary No. 168 dtd. 03.03.2023 and
released the vehicle without taking any action. (Copy enclosed)
: Reported - Nil
: NA
: Only Driver (i.e. insured himself) - not injured
: All have been verified from original & found in order.
: M/s Frontier Motocorp, Jabalpur Est No. JC-KP1-2223-003418 dtd.
04.03.2023
: As per the statement mentioned in the claim form/ Police Intimation
and as revealed from the driver (i.e. insured himself), that the vehicle
was going through aforesaid area, on the way nearby aforesaid spot,
at turning vehicle suddenly went out of control and further fell/
overturned / turned turtle at the road side ditch, causing the relevant
damages.

6 Other Details of Survey

The vehicle was inspected thoroughly by the undersigned before &
after dismantling. It was revealed that cause and nature of the
accident was found confirmatory with respect to extent of damages.
Details of Damages/
(a) discussions /observations & : As such the claim was discussed in length along with insured &
Assessment etc.
workshop people , thus the assessment has been worked out as
under. (Please see the Annex. / Excel sheet for the breakup of
assessment/ Recommendation in the next page onwards)
Re-Inspection/Bill check Also carried out on ....2023. All the replacement & repairs were found
Details
(b) : in order. Bills have also been checked and found in order. None of the
bills are short. Please note bills submitted on ....03.2023
(c) IMP Note/Remarks/etc. : Payment to the Workshop under Tie Up

(SANJEEV AGRAWAL)
SLA-4925 (Val.09.08.2025)
 Sanjeev Agrawal (SLA-4925)
Insured : Mr. Ankit Sahu S/o Shri Tikaram Sahu Vehicle No. : MP20CH5660
Policy No. `0209003122P104658336 (0% Depn. Policy) Date of Reg. : 30.08.2018
Validity 23.08.2022 to 22.08.2023 Date of Acc. : 03.03.2023
Age of Vehicle on Date of Accident : Exceeding 1 yr but not exceeding 2 yrs
Excess (Re): 1000
0% : Rubber/Plastic 10% :Metal 0% : Glass
"R" Not Marked "G"

Sr. No. PARTS Remarks Estimated Assessed GST

1 COOLANT PREMIX (40:60) L-001 42.40
BRACKET ASSY, SIDE BUMPER
2 330.00 257.81 28
MTG,REAR-RH
3 ASSY. INTERCOOLER 7190.00 5617.19 28
4 ASSY CONDENSER SDE ENG BEHR 8973.00 7010.16 28
5 RADIATOR ASSY 5286.00 4129.69 28
6 LOWER LINK ASSY,LH 4650.00 3632.81 28
7 ASSY FRONT PIPE 4141.00 3235.16 28
8 ASSY SUCTION PIPE PET DSL 1132.00 884.38 28
9 ASSY SUCTION 1623.00 1267.97 28
10 ASSY WHEEL ARCH FRONT LH 842.00 657.81 28
11 MUD LINER, FRONT-RH 401.00 313.28 28
12 SPLASH GUARD FRONT BUMPER 708.00 553.12 28
ASSY MBR RADIATOR MTG BOTTOM
13 929.00 725.78 28
COMP FEM
14 ASSY MBR RADIATOR SUPPORT 945.00 738.28 28
ASSY MBR RADIATOR SUPPORT BOTTOM
15 954.00 745.31 28
IN RH
16 ASSY HOOD LATCH COMP 333.00 282.20 18
17 FRONT BUMPER BOTTOM GRILL 1258.00 982.81 28
18 ASSY ORVM CORNER PIECE LH 124.00 96.88 28
19 FRONT BUMPER SKIN 2776.00 2168.75 28
20 CED ASSY FENDER COMP LH 2939.00 2296.09 28
21 CED ASSY FENDER COMP RH 2939.00 2296.09 28
22 CED ASSY HOOD SHELL 9315.00 7277.34 28
23 ASSY ROOF BEADING RH 666.00 520.31 28
24 ASSY ROOF BEADING LH 666.00 520.31 28
25 OUTER BELT FRONT DOOR LH 541.00 422.66 28
26 BLACK TAPE FRONT DOOR LH 186.00 0.00
27 BLACK TAPE REAR DOOR LH 195.00 0.00
ASSY.INNER REAR VIEW MIRROR
28 830.00 703.39 18
(ANTIGLARE)
29 BLACK TAPE FRONT DOOR RH 186.00 0.00
30 ROOF BOW FRONT 772.00 603.12 28
31 CED PANEL ROOF 8668.00 6771.88 28
ASSY LATCH POWER FRT DR 2
32 2038.00 1727.12 18
DRIVER SIDE
CED COATED DOOR SHELL ASSY,FRONT
33 10463.00 8174.22 28
DOOR,RH
CED COATED DOOR SHELL ASSY,FRONT
34 10463.00 8174.22 28
DOOR,LH
35 CED ASSY REAR DOOR SHELL LH 11274.00 8807.81 28
36 ASSY HOOD LATCH COMP 333.00 282.20 18
ASSY SIDE BRACKET FRONT
37 151.00 117.97 28
BUMPER LH

Assessment : 772266162.xls ; Page 4 of 6

 GRANIT_BLACK POP
38 6.00 0.00
UP KNOB
39 CAGE NUT [53(C 0805-12)M/S 112.00 0.00
40 INSULATION TAPE (WIRING) 20.00 0.00
GRANIT_BLACK POP
41 6.00 0.00
UP KNOB
42 WINDING GLASS FRONT DOOR LH 1794.00 1520.34 18
43 WINDING GLASS FRONT DOOR RH 1794.00 1520.34 18
44 ASSY ORVM ELECTRIC WITH SRL LH 4347.00 3683.90 18
45 ASSY ORVM ELECTRIC WITH SRL RH 4347.00 3683.90 18
46 ROOF BEAD SBT CLIP (3M) 476.00 403.39 18
47 FEVI KWIK 14.00 0.00
Parts Total: 118178.40 92805.99

FITMENT CHARGES REMOVING REFITING

1 CHARGRSQ 42834.00 6500.00

METALLIC COLOUR PAINTING: FRONT

2 5140.08 0.00
BUMPER -CITY C
METALLIC COLOUR PAINTING: ENGINE
3 5996.76 0.00
HOOD (BONNET) - CITY C
METALLIC COLOUR PAINTING: FRONT
4 3712.28 0.00
FENDER (RH/LH) - CITY C
PLASTIC COMPONENT WELDING/REPAIR
S/PAINTING METALLIC COLOUR
5 PAINTING: FRONT FENDER (RH/LH) -CITY 3712.28 0.00
C
METALLIC COLOUR PAINTING: FRONT
6 4997.30 0.00
DOOR (RH/LH) EACH -CITY C
METALLIC COLOUR PAINTING: REAR
7 4069.82 0.00
DOOR(RH/LH) EACH -CITY C
OUTSIDE WELDING / REPAIR CHARGES
8 18644.00 6500.00
CUTTING WELDING CHARGES
AC GAS REFILLING- R134A
9 3009.00 1500.00
(BEHR/VOLTAS) AC GAS CHARGES
PLASTIC COMPONENT WELDING/REPAIR
10 21830.00 0.00
S/PAINTING PANTING CHARGES
METALLIC COLOUR PAINTING: ROOF -
11 6996.22 0.00
CITY C
BALANCE WHEEL WHEEL REMOVED
12 361.08 306.00
EACH
FRONT WHEEL ALIGNMENT CHECK AND
13 451.35 382.50
ADJUST
DIAGNOSIS CHARGES DIAGNOSIS
14 4130.00 1500.00
CHARGE
VEHICLE OFF ROAD HELPLINE CHARGES
15 1829.00 1500.00
TOWING CHARGES
OUTSIDE WELDING / REPAIR CHARGES
16 24190.00
CUTTING WELDING CHARGES
17 FITMENT CHARGES BRAEK BLEADING 6490.00 200.00
REPLACE FRONT WINDSCREEN GLASS
18 METALLIC COLOUR PAINTING: REAR 1564.68 1326.00
DOOR(RH/LH) EACH -CITY C
METALLIC COLOUR PAINTING: REAR
19 3712.28 0.00
QTR PANEL (RH/LH) EACH -CITY C
PLASTIC COMPONENT
20 WELDING/REPAIRS /PAINTING METALLIC 3712.28 0.00
COLOUR PAINTING: REAR QTR PANEL
(RH/LH) EACH - CITY C
Assessment : 772266162.xls ; Page 5 of 6
 METALLIC COLOUR PAINTING: RUNNING
21 1570.58 0.00
BOARD-CITY C
PLASTIC COMPONENT WELDING /
22 REPAIRS / PAINTING METALLIC COLOUR 1570.58 0.00
PAINTING: RUNNING BOARD-CITY C
PLASTIC COMPONENT WELDING/REPAIR
23 4997.30 0.00
S/PAINTING FRONT DOOR PANTING
PLASTIC COMPONENT WELDING/REPAIR
24 4069.82 0.00
S/PAINTING REAR DOOR REPIER
METALLIC COLOUR PAINTING: TAIL
25 7567.34 0.00
GATE -CITY C
METALLIC COLOUR PAINTING: REAR
26 4711.74 0.00
BUMPER -CITY C
27 FULL BODY PAINTING 0.00 40000.00
Labour Total: 191869.77 59714.50
Total parts estimated & assessed (Before Depreciation) 118178.40 92805.99
GST on Parts As Applicable (Before Depn) ** 24605.00
Parts Total Incl GST (Before Depreciation) ** 117410.99
Depn. on Rubber / Plastic Parts i.e. 0% incl GST on Rs. 0.00 −− 0.00
Depn. on Metal Parts i.e. 0% incl GST on Rs. 117410.99 −− 11741.10
Net Parts Estimated & Assessed 118178.40 105669.89
Add- Entry Tax on Parts 0.00% 0.00 0.00
Add -Labour Charges 191869.77 59714.50
Add- GST on Labour 18.00% 0.00 10748.61
Total claim estimated and assessed 310048.17 176133.00
Less- Excess ** 1000.00
Total claim estimated and assessed 310048.17 175133.00
Less - Depn 12.5% on painting incl GST i.e. on Rs. 0.00 ** 0.00
Less - Salvage Realizable ** 1089.27
Net Claim Estimated & Assessed 310048.17 174043.73
Say Rs.: 174044.00
The net claim is recommended for Rs. /- (Rupees Thousand Only) subject to the terms and conditions/exclusion
of the insurance policy.
Salvage Already deducted above
Encls: Photographs ... Nos. + fee bill+ other relevant Documents.

(SANJEEV AGRAWAL)
SLA-4925 (Val.09.08.2025)

Assessment : 772266162.xls ; Page 6 of 6