V.K. SABOO, B.E. (Hons.

)Mech

INTRIM REPROT

Surveyor & Loss Assessor

Date April 8, 2008,
SLA 2332 Exp. 13.6.2012
--------------------------------------------------------------------------------------------------------------------------MOTOR SURVEY REPORT (INTRIM)
This report is issued `Without Prejudice, in respect of cause and extent of loss/damages and subject
to terms and conditions of the Insurance Policy.
Policy Number
Period Covered
IDV:

:
:

1. INSURERS:
(Address)
Phone Number
2. INSRUED:
(Address)
Phone Number .
3. (a) Financiers:

:
:
:

4. Vehicle Particulars: (Verified.)

(a). Registered. Owner
(b). Registered No.
(c). Date of Registration
(d). Chassis Number
(e). Engine Number
(f). Make
(g). Type of Body
(h). Class of vehicle (Use)
(i). Pre-accident Condition
(j). Registered Laden Weight
(k). Un-laden Weight
(l). Fitness Certificate No. Valid up to
(m). T.L. No. & Tax paid up to
(n). Passenger/load carrying capacity

:
:
:
:
:
:
:
:
:
:
:
:
:
:

5. Drivers Particulars (Verified.)

(a). Name of Driver
(b). Motor Driving License No.
Date of Issue
Valid up to
(c). Issuing authority
(d). Type of License
(e). Badge Number
(f). Endorsement On License if any.

:
:
:
:
:
:
:
:

------------------------------------------------------------------------------------------------------------------------File KL 11 AA 2025 maruti swift Room No.5, I Floor

Page 1 of 4

YMCA Shopping Complex

Calicut 673001.
Ph. Off: 0495-2768558, Res. - 2741472 Mobile No. 98470 03839
E-mail ID: vksaboo@sify.com

V.K. SABOO, B.E. (Hons.)Mech

INTRIM REPROT

Surveyor & Loss Assessor

Date April 8, 2008,
SLA 2332 Exp. 13.6.2012
--------------------------------------------------------------------------------------------------------------------------6. (a). Date & time of accident
:
(b). Place of accident
:
(c). Place of Survey (Name and
Address of the garage)
:
(d). Date of which request for survey
was received from the company
:
(e). Date & time of Survey
:
7. (a). The accident has been reported
to the police
(b). Name of the Police Station
(c). Station Diary No.
(d). Panchanama has been carried out
(e). Action taken by the police

:
:
:
:
:

8. (a). Has any third party involved in the

accident
(b). If Yes, give full details of fatal/
non-fatal injuries and damages to
third party property.
Chassis No. Physically found
Engine No. Physically found

:
:
:
:

The chassis no and engine no physically found tally with RC book.

CAUSE OF ACCIDENT:The cause of accident reported in the claim form reads as under:SURVEYORS OPINION:The cause of accident seems to be correct and damages found on the vehicle tallied.
Labour and replacement of parts recommended by me in my assessment is related to the nature and
cause of this accident.
INSURED CLAIM:DESCRIPTION
Labour Charges
Service Tax 12.24%
Cost of parts incl. VAT
TowingChargs
Sub Total
5 Additional estimate:
TOTAL
1
2
3
4

Rs.
Rs.
Rs.
Rs.
Rs.

AMOUNT
0.00
0.00
0.00
0.00
0.00
0.00
0.00

------------------------------------------------------------------------------------------------------------------------File KL 11 AA 2025 maruti swift Room No.5, I Floor

Page 2 of 4

YMCA Shopping Complex

Calicut 673001.
Ph. Off: 0495-2768558, Res. - 2741472 Mobile No. 98470 03839
E-mail ID: vksaboo@sify.com

V.K. SABOO, B.E. (Hons.)Mech

INTRIM REPROT

Surveyor & Loss Assessor

Date April 8, 2008,
SLA 2332 Exp. 13.6.2012
--------------------------------------------------------------------------------------------------------------------------DETAILS OF DAMAGES
BODY CABIN GLASS COWL
UPHOLSTERY SEAT GRILL
BEEDING
EMBLEM LOCK WINDER DOORS
MUDGUARDS BONNET DICKY ETC.
LAMPS SWITCHES BATTERY
WIRING
METERS AND EXTRA/ELECTRICAL
FITTINGS.
Battery No.
KM Reading.
FRONT SUSPENSION MAIN AND SUB
AXLES SHOCK ABSORBES
CONTROLS
INKAGES.
Main axle No.

STEERING/FORK ASSY WHEEL BOX

SHAFTS LINKAGES & CABLES.

SPRING SETS SHACKLES HANGERS

BUSHES

CHASSIS FRAME ASSY.

Chassis No

PAINTING/POLISHING

DETAILS OF DAMAGES
ENGINE RADIATOR COOLING
IGNITION LUBRICATION SYSTEMS
LINKAGES & CABLES FUEL TANK &
LINES & AC SYSTEM
8
------------------------------------------------------------------------------------------------------------------------File KL 11 AA 2025 maruti swift Room No.5, I Floor
Page 3 of 4

YMCA Shopping Complex

Calicut 673001.
Ph. Off: 0495-2768558, Res. - 2741472 Mobile No. 98470 03839
E-mail ID: vksaboo@sify.com

V.K. SABOO, B.E. (Hons.)Mech

INTRIM REPROT

Surveyor & Loss Assessor

Date April 8, 2008,
SLA 2332 Exp. 13.6.2012
--------------------------------------------------------------------------------------------------------------------------Engine No.
CLUTCH PEDAL LEVER
LINKAGES
AND CABLES

GEAR BOX ASSY LEVER LINKAGES

AND CABLES
PROPELLOR SHAFTS BED YOKE &
TEETH TRANSMISSION CHAIN
REAR AXLE ASSEMBLY CROWN
WHEEL & PIN
BRAKE PEDAL LEVER VALVE &
CYLINDERS CABLES HOSES PIPES
SHOES & BRAKE DRUMS
TYRE WHEEL DISC WHEEL RIM
HUB CAPS
&
OTHER ITEMS
PHOTOGRAPHS

10
11

12
13

14

15

Nos. color photos taken by me with

negatives are enclosed.

------------------------------------------------------------------------------------------------------------------------File KL 11 AA 2025 maruti swift Room No.5, I Floor

Page 4 of 4

YMCA Shopping Complex

Calicut 673001.
Ph. Off: 0495-2768558, Res. - 2741472 Mobile No. 98470 03839
E-mail ID: vksaboo@sify.com