Submitted to NIAC Claims Hub, Visakhapatnam. Page 1 of 8

SURVEYOR STAKE CODE

Survey Report No. Date of Report: 03/Feb/2015

MOTOR SURVEY REPORTDate of allotment Place of survey C C No.

Received on

Spot Surveyor DOES NOT ARISE

Date of Re-Inspn. Assessed loss Rs.0

Policy issuing Office THE NEW INDIA ASSURANCE COMPANY LIMITED

Office code

1 Name of the Insured Mr.

2 Phone and Mobile Nos. of insured

3 Address for communication

4 Contact person & Mobile No. 0 -

5 Present Registered owner 0 With effect from

POLICY PARTICULARS

6 Policy number Period of Insc:

7 Endorsements (IMTs imposed)

8 I.D.V. of the vehicle & accessories For Vehicle: For accessories:

9 HP/Hypothecation detailsHypothecated to

Date of HPA

10 Endorsement No. on policy NIL

11 Endorsement type (Transfer/LPG/Electrical fittings/Others) NIL

VEHICLE DETAILS

12 b) Year of Mfg.

c) Date of Regn.

d) Make e) Class of vehicle

13 Chassis No. 14) Engine No.

15 Colour of vehicle 16) OMR

17 Type of body 18) Carrying capacity 19) Cubic capacity:

20 ULW RLW: Payload:

From To From To

21 22) Fitness validity

23 Registration validity 24) Permit validity

25 Permit No. Not applicable 26) Type of permit Not applicable

27 Route / Area of operation Not applicable

Dates of survey and subsequent visits

a) Registration Number

Tax paid for period

Submitted to NIAC Claims Hub, Visakhapatnam. Page 2 of 8

28 Trip sheet No. & Date Not applicable Goods carried NOT APPLICABLE

29 Gross weight carried Not applicable 29A) No. of persons carried Not applicable

30 Nature of Fuel (Petrol, LPG, CNG, Diesel, Dual-fuel, Hybrid, etc.) Petrol

31 Alteration in the vehicle if any, reg fuel, extra fittings in contravention of RC No

32 Whether the alteration noted above is duly endorsed by RTO Not applicable

33 If there is any alteration, furnish the details thereof Not applicable

34 State, whether such alteration is material to this accident. Not applicable

DRIVER DETAILS

35 Name of Driver 0 Date of Issue

36 Capacity in which the vehicle was driven Date of renewal

37 DL Number 38) Issued by

39 Type of vehicle From To Type of vehicle From To

MCWOG MCWG

LMV-NT LMV-TV

HMV/HTV Others - Specify

OTHERS Others - Specify

40 Badge number NIL w.e.f. Date

41 Valid for class of vehicle under claim? Yes 42) Valid as on the date of accident? Yes

ACCIDENT PARTICULARS

43 Date of accident 44) Time of accident

45 Place of accident

46 Was any third party vehicle involved? No 47) Was any TP property involved? No

48 TP Vehicle/property damage details NOT APPLICABLE

49 Details of TP injury / death NOT APPLICABLE

50 CAUSE OF ACCIDENT

POLICE RECORDS

51 FIR / CSR / GD Entry Number DOES NOT ARISE Date of FIR/CSR/GDE

52 Name of Police station DOES NOT ARISE

53 Reasons for not making FIR / GD entry NO T.P. INVOLVEMENT

54 Compromise letter obtained if any DOES NOT ARISE

Submitted to NIAC Claims Hub, Visakhapatnam. Page 3 of 8

DETAILS OF REPAIRER

55 a) Name & address of Repairer 0

0

(b) Contact Person and Contact No(s).

(c) Is the Repairer authorised service centre for the subject vehicle? Yes

(d) Estimated amount & Supplementaries Rs.0.00 Rs.0.00

SUMMARY OF ASSESSMENT

Item of assessment Amount - Rs.

Labour charges (including Taxes if any) 0.00Parts recommended at cost 0.00Part recommended at Normal depreciation @ 0% 0.00Parts recommended at 30% Depreciation 0.00Parts recommended at 50% Depreciation 0.00Towing charges (incl. Spot repair charges) 0.00Additions and Deletions from Assessment Sheet 0.00

Gross assessed loss 0.00Less: Compulsory excess 0.00Less: Imposed Excess 0.00Less: Voluntary Excess 0.00Less: Salvage value 0.00

NET ASSESSED LOSS 0.00

NET PAYABLE LOSS (ROUNDED OFF TO) 0Payment to be made to insured or Repairer or Financier InsuredIf payment is to be made to Repairer, whether Satisfaction Voucher from the insured is obtained? Not applicable

CERTIFICATIONa) The Engine and Chassis numbers were physically verified and found tallied with the Policy and R.C.b) The cause of accident is relevant to the observed damage.c) Supplementary estimate(s) are relevant and hence considered.d) The recommended repairs and replacements are relevant. e) The repaired vehicle was reinspected after repairs to my satisfaction.f) Wherever Repairers are not authorised dealers, rates of spares were verified with the rates of authorised dealers. g) Damage observed in the spot survey report are in agreement with the observed damage.h) Damage which are not relevant to the cause of accident are also mentioned and not considered for assessment.

R C Book Yes Yes Trip Sheet Not applicable Not applicableTax card No No Others (Specify) Driving Licence Yes Yes Others (Specify) Permit Not applicable Not applicable Others (Specify)

Any other observations

NIL

Signature of Surveyor.

Verification with originals

Verified (Yes / No)

Copy enclosed ( Yes / No )

Verification with originals

Verified (Yes / No)

Copy enclosed ( Yes / No )

THIS REPORT IS ISSUED WITHOUT PREJUDICE IN RESPECT OF CAUSE, NATURE AND EXTENT OF LOSS/DAMAGE AND IS SUBJECT TO THE TERMS AND CONDITIONS OF THE POLICY OF INSURANCE

Seal

Submitted to NIAC, Claims Hub, Visakhapatnam Page 4 of 8

Name of surveyor: B.PYDIRAJU Date of accident CC No. 0

Details of damage and assessment 30/Dec/1899 0 0

LABOUR CHARGES All values in RupeesS/N Item of work Description of damage Relevancy Job Estimated Billed Assessed Allowable Tax Net Amount1 Front bumper Yes R&R 0.00 0.00 0.002 Radiator grille Yes R&R 0.00 0.00 0.003 Headlamp units Yes R&R 0.00 0.00 0.004 Fender panels Yes R&R 0.00 0.00 0.005 Fender lining Yes R&R 0.00 0.00 0.006 Windshield glass Yes R&R 0.00 0.00 0.007 Dashboard assembly Yes R&R 0.00 0.00 0.008 Steering column cover Yes R&R 0.00 0.00 0.009 Wiring harness (partial) Yes R&R 0.00 0.00 0.00

10 Brake pedal Yes R&R 0.00 0.00 0.0011 Front suspension arm (2) Yes R&R 0.00 0.00 0.0012 Front stabilizer bar Yes R&R 0.00 0.00 0.0013 Front drive shafts Yes R&R 0.00 0.00 0.0014 Rear axle shaft Yes R&R 0.00 0.00 0.0015 Engine assembly Yes R&R 0.00 0.00 0.0016 Transmission RH case Yes D&A 0.00 0.00 0.0017 Radiator assembly Yes R&R 0.00 0.00 0.0018 AC condenser Yes R&R 0.00 0.00 0.0019 Member front upper Yes R&R 0.00 0.00 0.0020 Apron panel RH Yes C&W 0.00 0.00 0.0021 Panel lamp support RH Yes C&W 0.00 0.00 0.0022 Cross member assembly Yes C&W 0.00 0.00 0.0023 Panel front hood Yes Paint 0.00 0.00 0.0024 Member front upper Yes Paint 0.00 0.00 0.0025 Panel fender apron RH Yes Paint 0.00 0.00 0.0026 Panel lamp support RH Yes Paint 0.00 0.00 0.0027 Cross member dash panel Yes Paint 0.00 0.00 0.0028 Panel front fender RH Yes Paint 0.00 0.00 0.0029 Wheel alignment Yes Align 0.00 0.00 0.0030 Refrigerant gas recovery &/or recharge Yes R&R 0.00 0.00 0.0031 Towing charges Yes Others 0.00 0.00 0.0032 Less: For combination jobs on painting Less: 12.5 % Painting Depreciation 0.00 0.00

Insert lines before this row if necessary 0.00Total 0.00 0.00 0.00 12.4% 0.00 0.00

Submitted to NIAC, Claims Hub, Visakhapatnam Page 5 of 8

SPARES CC No. 0 0S/N Part Damaged Description of damage Relevancy Material Deprn. Estimated Billed Bill S.No. Assessed Allowable Tax Dep. Amt. Net Amount1 Panel comp front hood Pressed in, crushed & crumpled Yes Others 0% 0.00 0.00 0.00 0.00 14.5% 0.00 0.002 Hinge comp front hood RH Bent and deshaped Yes Others 0% 0.00 0.00 0.00 0.00 14.5% 0.00 0.003 Hinge comp front hood LH Bent and deshaped Yes Others 0% 0.00 0.00 0.00 0.00 14.5% 0.00 0.004 Panel lamp support RH Crushed and crumpled Yes Others 0% 0.00 0.00 0.00 0.00 14.5% 0.00 0.005 Cross member comp front lower Crushed and crumpled Yes Others 0% 0.00 0.00 0.00 0.00 14.5% 0.00 0.006 Cross member hood lock Pressed in, twisted & deformed Yes Others 0% 0.00 0.00 0.00 0.00 14.5% 0.00 0.007 Brace hood lock Twisted and deformed Yes Others 0% 0.00 0.00 0.00 0.00 14.5% 0.00 0.008 Panel front fender RH Badly crushed & crumpled Yes Others 0% 0.00 0.00 0.00 0.00 14.5% 0.00 0.009 Lining front fender RH Torn Yes Plastic 50% 0.00 0.00 0.00 0.00 14.5% 0.00 0.00

10 Panel comp apron side RH Crushed and collapsed Yes Others 0% 0.00 0.00 0.00 0.00 14.5% 0.00 0.0011 Member comp apron side RH Deflected and deshaped Yes Others 0% 0.00 0.00 0.00 0.00 14.5% 0.00 0.0012 Bumper front alto dom minor Crushed and torn Yes Plastic 50% 0.00 0.00 0.00 0.00 14.5% 0.00 0.0013 Grille front bumper Yes Plastic 50% 0.00 0.00 0.00 0.00 14.5% 0.00 0.0014 Garnish front bumper Yes Plastic 50% 0.00 0.00 0.00 0.00 14.5% 0.00 0.0015 Cover front bumper Yes Plastic 50% 0.00 0.00 0.00 0.00 14.5% 0.00 0.0016 Panel heat insulator Crumpled Yes Others 0% 0.00 0.00 0.00 0.00 14.5% 0.00 0.0017 Extension front bumper Yes Plastic 50% 0.00 0.00 0.00 0.00 14.5% 0.00 0.0018 Stay comp front bumper RH Yes Others 0% 0.00 0.00 0.00 0.00 14.5% 0.00 0.0019 Stay comp front bumper LH Yes Others 0% 0.00 0.00 0.00 0.00 14.5% 0.00 0.0020 Emblem (S) mark E3 Yes Rubber 50% 0.00 0.00 0.00 0.00 14.5% 0.00 0.0021 Glass set front Shattered Yes Glass 0% 0.00 0.00 0.00 0.00 14.5% 0.00 0.0022 Molding windshield Inevitable replacement Yes Rubber 50% 0.00 0.00 0.00 0.00 14.5% 0.00 0.0023 Sealant kit Inevitable replacement Yes Rubber 50% 0.00 0.00 0.00 0.00 14.5% 0.00 0.0024 Headlamp unit RH Broken Yes Plastic 50% 0.00 0.00 0.00 0.00 14.5% 0.00 0.0025 Lamp assembly side turn signal Broken Yes Plastic 50% 0.00 0.00 0.00 0.00 14.5% 0.00 0.0026 Radiator assembly Dislocated and misaligned Yes Others 0% 0.00 0.00 0.00 0.00 14.5% 0.00 0.0027 Fan engine cooling Dislocated and misaligned Yes Plastic 50% 0.00 0.00 0.00 0.00 14.5% 0.00 0.0028 Knuckle steering RH Yes Others 0% 0.00 0.00 0.00 0.00 14.5% 0.00 0.0029 Strut front susp Dislocated and misaligned Yes Others 0% 0.00 0.00 0.00 0.00 14.5% 0.00 0.0030 Arm assy front susp control (2) Bent and deshaped Yes Others 0% 0.00 0.00 0.00 0.00 14.5% 0.00 0.0031 Case transaxle RH Bent and deshaped Yes Others 0% 0.00 0.00 0.00 0.00 14.5% 0.00 0.0032 Mounting engine front RH Bent and deshaped Yes Rubber 50% 0.00 0.00 0.00 0.00 14.5% 0.00 0.0033 Bracket engine mounting RH Dislocated and misaligned Yes Others 0% 0.00 0.00 0.00 0.00 14.5% 0.00 0.0034 Stabilizer bar front Bent and deshaped Yes Others 0% 0.00 0.00 0.00 0.00 14.5% 0.00 0.0035 Bushing stabilizer bar (4) Deformed Yes Rubber 50% 0.00 0.00 0.00 0.00 14.5% 0.00 0.0036 Mount stabilizer bar (2) Deformed Yes Others 0% 0.00 0.00 0.00 0.00 14.5% 0.00 0.0037 Bracket stabilizer mount (2) Deformed Yes Others 0% 0.00 0.00 0.00 0.00 14.5% 0.00 0.0038 Shaft assembly front drive RH Dislocated and misaligned Yes Others 0% 0.00 0.00 0.00 0.00 14.5% 0.00 0.0039 Rod assembly lateral Hit at middle, bent & deshaped Yes Others 0% 0.00 0.00 0.00 0.00 14.5% 0.00 0.0040 Absorber assembly rear shock Dislocated and misaligned Yes Others 0% 0.00 0.00 0.00 0.00 14.5% 0.00 0.0041 Axle comp rear Dislocated and misaligned Yes Others 0% 0.00 0.00 0.00 0.00 14.5% 0.00 0.00

Submitted to NIAC, Claims Hub, Visakhapatnam Page 6 of 8

SPARES CC No. 0 0S/N Part Damaged Description of damage Relevancy Material Deprn. Estimated Billed Bill S.No. Assessed Allowable Tax Dep. Amt. Net Amount42 Tie rod comp steering Dislocated and misaligned Yes Others 0% 0.00 0.00 0.00 0.00 14.5% 0.00 0.0043 Wheel rim Twisted and deformed Yes Others 0% 0.00 0.00 0.00 0.00 14.5% 0.00 0.0044 End comp steering tie rod Dislocated and misaligned Yes Others 0% 0.00 0.00 0.00 0.00 14.5% 0.00 0.0045 AC condenser Dislocated and misaligned Yes Others 0% 0.00 0.00 0.00 0.00 14.5% 0.00 0.00

Insert lines before this row if necessary Choose type of material 0.00 14.5%Total 0.00 0.00 0.00 0.00

Parts allowed at cost 0% 0.00Parts at Normal Depreciation 0% 0.00Parts at 30% Depreciation 30% 0.00Parts at 50% Depreciation 50% 0.00Total assessment of spares 0.00TOTAL (Labour + Spares) 0.00

Add: Towing charges 0.00Add: Others (if any) [Specify or delete this cell] 0.00

0.00Less: Compulsory excess 0.00

Imposed Excess 0.00Voluntary Excess 0.00Salvage value 0.00Others (if any) [Specify or delete this cell] 0.00

NET ASSESSED LOSS 0.00

Signature of Surveyor.

SURVEY FEE BILL

B.PYDIRAJU THE NEW INDIA ASSURANCE COMPANY LIMITED,

SURVEYOR & LOSS ASSESSOR Claims Hub, SLA NO-17129, EXP-06/12/2012 47-10-12, Pavan Paradise, D.NO.54-12-28/A, H.B.Colony, 4th Flr, 2nd Lane, Dwarka Ngr., Bhanunagar Visakhapattnam - 530016 VISAKHAPATNAM-530022 Policy issuing office: 0

MOBILE-9440389345 SWIS ID

BILL NO. - DATE 03/02/2015

INSURED 0

POLICY NO. 0

IDENT. MARK - MAKE -

ESTIMATED LOSS Rs.0 ASSESSED LOSS Rs.0

PROFESSIONAL FEE

Final Survey Rs. 750.00

Reinspection

0

CONVEYANCE EXPENSES Rs. 500.00

Local conveyance

0

DAILY ALLOWANCE

One full day

Half-a-day

PHOTO CHARGES 0 10 Rs.10.00 Rs. 100.00

OTHER (OUT OF POCKET) EXPENSES

Photos CD burning charges

Courier, etc.

0

0

ADD: Service Tax on Gross amount 0.00% Rs. -

(EXEMPTED as per Notification No. 4/2007 dated 01.03.2007)

Total Rs. 1,350.00

TOTAL (ROUNDED OFF) Rs. 1,350.00

E.&O.E.

Space for any comments.

B.PYDIRAJUSurveyor & Loss Assessor

THE NEW INDIA ASSURANCE CO. LTD. MOTOR OD - CLAIMS HUB REGIONAL OFFICE, VISAKHAPATNAM

CC No 0Name of insured 0Date of accident 30/Dec/1899Policy No 0Vehicle No 0Name of repairer 0

Item of assessment Amount1 Labour charges 0.002 Parts allowed at cost 0.003 Parts allowed at Normal depreciation 0% 0.004 Parts allowed at 30% depreciation 0.005 Parts allowed at 50% depreciation 0.006 Towing charges (incl. Spot repair charges) 0.007 Others If any 0.00

Gross assessed loss 0.00 Less: Salvage value 0.00 Less: Compulsory Excess 0.00 Less: Imposed Excess 0.00 Less: Voluntary excess 0.00 Less: Others, if any 0.00

NET ASSESSED LOSS 0.00

NET PAYABLE LOSS (ROUNDED OFF TO) 0.00

Payment to be made to insured or Repairer InsuredIf payment is to be made to Repairer, wherther Satisfaction Voucher from Not applicableinsured is enclosed?

Cheque in favour of 0

Survey fee 750.00Conveyance 500.00Halting allowancePhoto charges 100.00OthersTaxesTotal 1,350.00

SUMMARY OF ASSESSMENT