ANNEXURE C TWO WHEELER Report should be on Survey Companys letterhead name and address .

. Based on the information given the following vehicle proposed for insurance has been physically inspected on//.. AM / PM, at __________________, belonging to Mr./Ms./M/s. ________________________________

VEHICLE NO.:___________________ CHASSIS NO.:____________________ MANUFACTURING YEAR: __________________ ODOMETER READING _______________ INSURANCE POLICY CHECKED YES/NO BREAK PERIOD MONTHS (LESS THAN 1) (MORE THAN 6)

MAKE/MODEL: ____________________ ENGINE NO.: _____________________ FUEL TYPE _______________________ RC COPY CHECKED YES/NO BREAK ININSURANCE YES/NO (MORE THAN 3) (MORE THAN 1 YEAR)

Details FRONT HEADLIGHT FRONT LEFT INDICATOR FRONT RIGHT INDICATOR FUEL TANK FRONT GUARD SIDE GUARD TAIL LIGHT TAIL LEFT INDICATOR TAIL RIGHT INDICATOR SILENCER TYRES FRONT TYRE MUD GUARD REAR TYRE MUD GUARD HORN SIDE STAND MAIN STAND FRONT FOOT GUARD (L & R) REAR FOOT GUARD (L & R) SPEEDOMETER INSTRUMENT CONSOLE COLOUR OF VEHICLE

Description INTACT/BROKEN INTACT/BROKEN INTACT/BROKEN INTACT/PRESSED/SCRATCH/RUS TED INTACT/PRESSED/SCRATCH/RUS TED INTACT/PRESSED/SCRATCH/RUS TED INTACT/BROKEN INTACT/BROKEN INTACT/BROKEN INTACT/PRESSED/SCRATCH/RUS TED BAD/GOOD/AVERAGE INTACT/PRESSED/SCRATCH/RUS TED INTACT/PRESSED/SCRATCH/RUS TED INTACT/BROKEN INTACT/BROKEN/RUSTED INTACT/BROKEN/RUSTED INTACT/BROKEN/RUSTED INTACT/BROKEN/RUSTED INTACT/BROKEN INTACT/BROKEN

Remarks (Details of visible damages noticed)

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We confirm the observations cited above are in respect of physical inspection of the vehicle. RECOMMANDED FOR INSURANCE YES/ NO

It is hereby declared and agreed that all pre existing damages to the vehicle that has occurred prior to commencement of cover are excluded from the scope of the policy. I confirm the observations cited above in respect of my vehicle.

_____________________ Signature of Customer

______________________ Signature of Inspecting Officer

______________________ (Counter Sign SM/BM)

Note: - Employee Name & ID to be mentioned, if done by employee; Counter sign by SM/BM if done by CSO.

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