CLAIM ASSESSMENT REPORT

Private & Confidential

WITHOUT PREJUDICE

Ref. No.: P232400088 Date: 16/03/2024

This report is issued, subject to the terms and condition of the Insurance Policy and admission of liability by the
Insurance Company.

Subject : Claim for Vehicle Registration No. UP73AE3146, Accident Date : 10/03/2024
Insured : TEST NAME
Policy No. : P116032024
Insurance Period : 16/04/2023 To 15/04/2024
Claim No. : C116032024
Appt. Officer : Test Appointee Officer

Policy No. : P116032024

Insurance Period : 16/04/2023 To 15/04/2024
Insurance Particulars
Insurer : National Insurance Co. Ltd.
C - 7/34, GORAS BUILDING, LAHURABIR VARANASI-
221001
Insured : TEST NAME
INSURED TEST ADDRESS M-9876543211
Policy No./Cover Note No. : P116032024
Period of Policy : 16/04/2023 To 15/04/2024
IDV : Rs. 87000.00
Vehicle Particulars RC: YES
Registration No. : UP73AE3146
Registered Owner : TEST NAME
Date of Registration : 18/02/2024
Chasis No. : MBLHAW219P9M01271 Physically Verified :Yes
Engine No. : HA11E7P9M04128 Physically Verified :Yes
Engine Capacity : 97.20 CC
Vehicle Make : HERO MOTOCORP
Vehicle Model : SPLENDOR PLUS
Vehicle Variant : XTEC BSVI
Type of Body : SOLO WITH PILLION
Colour of Vehicle : RED BLACK
Class of Vehicle : TWO WHEELER
Seating Capacity : 2
Odometer Reading : 67676 Kms
Fuel used as per RC : PETROL
Tax paid upto : OTT
Bank Particulars
Bank Name : AXIS BANK
Bank Address : Test Place

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

Email ID: info@paramountservices.co.in, Mobile No. +91 98914 55847
Bank Account No. : 123456789
IFSC Code : UTI01234
Driver Particulars DL: YES
Name of the Driver : TEST DRIVER
Driver DOB : 10/01/1991
Driver Address : TEST DRIVER ADDRESS
Relation with the insured : Test Relation with customer
Driving License Number : TESTDL1234
Valid from : 10/01/2020 Upto 10/01/2030
Type of License : LMV
Type of Vehicle Allowed To Drive : LMV
Accident Particulars
Date and Time of Accident : 10/03/2024
Place of Accident : Test Location of Loss
Place of Survey : TEST WORKSHOP ADDRESS
Date of request for Survey : 10/03/2024
Date and Time of Survey : 10/03/2024 01:45 AM
Particulars of Police Report
Has accident been report to Police : No
Has Panchnama been carried out : No
Particulars of Third Party Injury / : No
Loss
Injury to Driver / Occupant ( If any ) : No
Description of Loss
Test Description of Loss
Cause and Nature of Accident
Test Nature of Loss
Original Estimate
Dated 10/03/2024 for Rs.42500.00 was submitted by Test Workshop
Observation
Test Observation on Survey
(Issued without Prejudice)

For PARAMOUNT SERVICES

(Authorized Signatory)

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

Email ID: info@paramountservices.co.in, Mobile No. +91 98914 55847
 Ref. No.:P232400088 UP73AE3146 Page 3 of 4

LOSS ASSESSMENT

In respect of Vehicle Registration No. UP73AE3146, Accident Date : 10/03/2024

(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 parts one 18.00 5000.00 - - 5000.00 -

2 parts two 18.00 5000.00 5000.00 - - -
3 parts three 18.00 5000.00 - 5000.00 - -
4 parts four 18.00 5000.00 - - - 5000.00
5 parts five 18.00 5000.00 5000.00 - - -

Total 25000.00 10000.00 5000.00 5000.00 5000.00

Add IGST @18% 4500.00 1800.00 900.00 900.00 900.00

Total 29500.00 11800.00 5900.00 5900.00 5900.00

@ 10.00% on Metal, 50.00% on
Less Dep Rub/Plast,10.00% on Glass Parts, 30.00% 1180.00 2950.00 590.00 1770.00
on Fibre Parts
Total 10620.00 2950.00 5310.00 4130.00

Total 23010.00

LABOUR CHARGES
S.no Description of Parts Remark Estimated O/F & Denting Painting
(Amt in Rs) (Amt in Rs) (Amt in Rs)
1 Parts Nine 4000.00 2000.00 2000.00
2 Parts Ten 4000.00 2000.00 2000.00
Total 8000.00 4000.00 4000.00
Add IGST @18.00% 1440.00 720.00 720.00
Total 9440.00 4720.00 4720.00
Less 0.00% on Labour, 12.50% of Painting 590.00
Total 4130.00
Net Labour Amount (O/F & D/B + Painting Labour) 8850.00

Summary of Estimate and Assessment of Loss

Total Cost of Parts 29500.00
Parts (Metal) 10620.00
Parts (Rub/Plast) 2950.00
Parts (Glass) 5310.00
29500.00 23010.00
29500.00 23010.00
Net Labour Charges 9440.00 8850.00
TOTAL 38940.00 31860.00
Compulsory Deductable (-) 1000.00
Less Salvage (-) 860.00
Less Voluntary Excess (-) 1000.00
Less Test (-) 1000.00
Add Towing Charge (+) 2000.00
TOTAL 38940.00 30000.00
Net Liability on Repair Basis 30000.00

PARTS TAX SUMMARY

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

1 18.00 19500.00 0.00 0.00 3510.00 23010.00

Grand Total 19500.00 0.00 0.00 3510.00 23010.00

LABOUR TAX SUMMARY

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

1 18.00 4000.00 0.00 0.00 720.00 4720.00

Grand Total 4000.00 0.00 0.00 720.00 4720.00

PAINTING LABOUR TAX SUMMARY

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

1 18.00 4000.00 0.00 0.00 720.00 4720.00

Grand Total 4000.00 0.00 0.00 720.00 4720.00

Net Liability
Based upon the assessment provided above, the final liability under the policy Works Out To Rs.30000.00
(Rupees Thirty Thousand ). The Final liability is subject to terms & condition of Insurance policy and
admission of liability by the insurer.
(Issued without Prejudice)

For PARAMOUNT SERVICES

(Authorized Signatory)

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

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