pdi

1. DISTRIBUTION COMPANY LIMITED
MUMBAI
ltlARINE CLAIMS
.
FAMiLIAR/SA TlON
ON THE
!lfAJVDA TOR DOCUME1VT A TIONS
TING EXPEDII10US
OF CLAlkfS
BY
TIlE lVEW INDIA ASSURANCE C01}1PANY LTD
************************

2. TMLDC LTD, MUJV1BAl
IMANDA TOR y DOCUMENTS
(j. Check Sheet -forwarding letter
e Carbon copy (~rE!(dse CIUlllan cum Sales Invoice
" Carbon copy of G; CIL. R.lR.R Note
• Hnver's statement in original
eE'J,'tinUlte in original
" Claim Bill in duplicate
" Copy (~lIYl()nitor.vNotice 011 the Carrier (Transporter)
" Surveyor Report with Survey Fee Receipt
OJ Photographs
Certificate ji-onl the Carrier
Bii/( Invoice)
• { .WI1tl Form du(v filled in (lnd signed
Spot Surve.v Report and Photographs (in case of enroute
major accident)
" .4 letter to requesting them to settle the claim on
Total Basis
Subrogation
ofAl/orney ( el."Ie extract of the Board Re,'iwlution )

3. Covering letter on the Letter head of the dealer
The Insurance Cell,
TMLD Co.Ltd.,
1, Forbes, 4th Floor,
Dr: V. B. Gandhi Marg,
Fort, Mumbai 400 001
Sub: Marine Insurance Claim in respect of vehicles bearing
Chassis No/Nos .
Dear Sir,
We forward herewith the following documents in respect of vehicles mentioned above for
submission to NIA and settlement. Please tick the documents enclosed:
1. Excise Challan - cum -Sales Invoice No dated (original/carbon copy to be
enclosed. )
2. G. C. Note/RRlLR No dated ( carbon copy to be enclosed)
3. Driver Report (in original on a plain sheet with his signature & Name)
4. Estimate ( in original)
5. Claim Bill ( in duplicate, in original and on the letter head)
6. Monitory Notice on the carrier ( copy)
7. Survey Report and fee receipt in original
8. Damage Certificate
9. Claim Form ( duly filled in and signed - in original)
10. Photographs
11. Final Repair bill ( tax bill in original)
12. FIR, Spot Survey Report and Photographs (whenever vehicle meets with major
accident en-route)
13. Letter addressed to New India ( in case of total loss - stating that the claim may
please be settled on total loss basis)
14. Letter of subrogation (for total loss only) along with a copy of the Power of
Attorney of the signing authority.
Thanking you,
Yours faithfully,
Name of the organization, signature, Name of the signatory, and Designation.

4. Ref No: Oate:20/05/2009
To
Insurance Cell,
Tata Motors Ltd.
Passenger Car Division
World Trade Centre, Centre-1
26m Floor, Cuffe Parade
Mumbai 400005
Sub: Ex works Sale Vehicle Marine/Motor Insurance Claim
Chassis no(s) MCA11071709003697CQZ
Dear Sir
We forward herewith the following documents for the purpose of claim under
transit insurance policy of Indica Car:
Please tick only on the documents enclosed
[5( Excise Challan cum Sales Invoice 971776690
/
dated 15103/2009
[3 Original GC Notel Bilti No. 12466 dated 16/03/2009
o )3urvey Report and Survey fee receipt in original
5t yOpy
a:r Ack. of monetary notice Le. carrier of delivery in form of Registered
of monetary notice to proof in original Post AD
yard stamped and signed by the transporter
f3Ypamage Certificate in Original.
~~Iaim Bill in duplicate.
g'
19'fiR and Spotinsurvey report if applicable.
Claim Form original
~fhotograph and negatives
gr Drivers Statement in original & copy of his license.
D Final Repair Bill in original (only for Repair Claims)
(i:( Letter
~..Repair of total loss original (for all claims)
Estimate in
o Letter of subrogation (for total loss claims)
ORe-inspection report (for motor claims only)
Please take our claim with New India Assurance Co. Ltd. for Rs. 701151.88
Thanking You.
Yourstp~
For C~c;rde Motors (India) Ltd .
Mr. Karpppasamy
Business Unit l-lead, Cochin
karuppasamyk@concordemotors.com

5. .~
HO RVI
SEV.A
Offices
MIs. TATA MOTORS LTD.
Pimpri, Pune - 1 018 No·1 46
No. :
REMARKS
Kms.
For Kishor Transport
Services Pvt
Auth.
1) Received goods enlirel'V at OWNER'S RiSK as delgH" above for carriage end tills ConsJgnmerr! note is Issued
~ Contract
2) The consignor expressly declares that above him sand di:scrtptio,,'1S in
bool,5 of account other related documents are in the terms and conditiorrs of
'ontriilc! which has read and I or explakned and a<X"..apts his agimt who hi." full power and light 10 book tile goods
• forwarding note, receipts on

6. ORIGINAl.
90110!3862621.fH.2G09
~e.lers
PDUeb-GrD~tr-OR09-00/14.
en.
( ) GRI.1IJER TRAf)[ CHileS f' ,M1f{EIlL V
Gm.tR TRAOCI..1}Ij(S M LID
4TH I'[I!.ISTM ~ tnll) Shp 00 3835S
[ffl !1INI rrrt PASS I BE 0106585 ~T 01.0S.06
BE 5050795 f)T 15.05.06
f.lACCG:!066&
Gr:IJI.IER1m
1 L.:00i8 M fJi)
4TH m:tETM I~ mAl) ,
lab IndIca Mrt:. <GLS) !flIt! m1f' Jjjtl1 A.G. UnIt, FOller ~t*iering, "1753I f.ngitie. <Ifni (1£ ill, 63!f,
1l9a CC, (r.m-w. -PE1T{(l! LPG) T1'ans<IXJ~ I !nios. t.1hf.<ll Ri11S, S Has. 16S165R 13 !'{<tdi<ll 'lyres, 2400 rtlLt R SeaUIgC.pwity
"II Drive!'. CololJf : I1etallic MG'r£-,'tIJREi' .
O~si~ Value (Rs.) 2"1;;; 2;'H " 1:3
lefts Dlscount (Rs.) 16.409,[32
Subtot.l (Ri>.) ::~5S.B2L 31
R!)(: (RI>.) 8.68')1,00
HlHtL (Rs.) c!64. ~:;10,31
vAT 8 12.5~ nR CST e 1~ (Rs. I S. 116, 4~j
GRIIMI> nlTAL Hh.) 269.626,74

7. Driver Report on a plain sheet of paper
DRIVER' REPORT
Name of the Driver
(full name as appearing in the
Driving licence)
Full Address
(As appearing in the driving licence)
Licence Details of the Driver:
Licence No.
Date and Place of Issue
Date of Expirey
Accident Details
Date and Place of Accident
( with District & State)
Transporters name, address and
Telephone/mobile No.
Short description of the accident
and the damages sustained to the
Vehicle/vehicles
Place:
Date: (Name of the driver & his signature)

8. Driver's Report
.Name of Driver J"..d..<3lf'rCL O~d;,)7o..{<::'.t:?u..- t-:5C1Pt"tJLcffJ;Yl
Address
, "'l.:::'J:.(. t<,pf.y~l4..."
Df:';X- ~ Eeef!ct)'!( Ka,.7 v...Jq.l='- ~)
Pvt
Transporter's Name & Tel. No. : r.{~7
Truck No
:K (~
Licence's Details
Licence No.
Date & place of issue
Date of expiry
Accident Details
Date
Place of accident
(with District & State)
Cause of Accident
Chassis No !to?( 76 7 Z~
Engine No : (!)C; ( 6 5"" D g
Model & Colour
: f ~ •• - ~ .. D1. /V~co1 ~?td
Damage due to the accident
Signature of driver or transport contractor
GWNDfrA
(Name: 63tJw,~l)
Date:
4'.

9. ONCORDE
PassengerCarDea~r
- -- I «- _ 1~~.---
--- -
----
--~._.-
-.-
-.-----«-« ---~-----_.
--"'.--,.
645 , 9001
416851 3500 1500[ 1
r-~ REAR BUMPEI~
45 GARNISH RH
1-.
GAS 57!).----<
136~~~AT WITH , TUBE
46900<-
FRONT ALIGNMENT
TYRE
<REA~<B<~1£..ER -~
--j--
''''WHEELSUSPENSION I ___
531851
58 EtJ_GINE R&RELEC!'.BICAI._
& I _____
:
NCI£:EL .. DISC _ A~.§.L_.< f~OO •
2100
66000
5000 1500'
5001 -< II
[500
400
7.00,
f--------=:;l
2325
5781
2325
1744
507 !
-.,--,- __ I I
2500 540
1940
6600
I
1500
1951
-2l.t!Q
~j----!=----
GRiLL 38<KNl!~KLE BEARING ..
-~
Terms &. Conditions
1 Payment of Ihe liU is to be done by the customer and the ,ame may be 3ubscQucntfy claimed from the ins.ursncc company.
In ca-se of cashles..s insurance products. cashless ru!es apply <..
2 This is coly a preltminary eslimate and actuaf i1fficunt will vary as p-er the ••. involved
o.-x
3 Taxes will hi-: Axtra & willtJe indudAr! in the final hi!! of repairs
4 Delivery against payment by casrl/DD In case norma! poricles I Ncar cashJoss rules In case of near cashless policios.
Your are reQUested to ~:ect a!llhe removed parts/Salvage althe time of !he dE:livery of your vehicle. If not colJected the same cannot be plOvided r:J1
1-1
!dCf t1ulc
Picaso feci free to call on uS tor any danflCabO!1 r-r.VARAOARAJ~ 'Iii! De pleased to oe of help.
;ssuring yo~ of our best ottenf1on
Thanking You
Yours. faithfully,
~f~,
Body ShO~ ~~-
CDPcorde Motors ( India) Limited :.;n;:J%Subs.;d;a:y of TiIA Motors Ltd.)
15;62/1 NeHny t/W5G,i P;:::nch~Y3t!;::GC·11!). Emdkuttii,l District Kefa!H - 682304.
Showroom _Tei. 0484-5602000101/02i03 Service _ 66020iOIiI112!i:!
, .":1~' . S2!es ?j-::h:~:~:o!'corde;-:-,oto"~..:0:': Se"JfCc.~:)cni'1@CDncordematofs.ccm Weh;iie: ''.COilcorden1otors.com
if
Rfl£.;t:L Ofhcf: . 3rd FeeL ;"~3naV.1~:M8 -;f1:?Y~ 13. H,.Y:ii M!)d; S:reet, i-tua~ma·Ci1Cwk. t••
1umbal· 400 001

10. On the letter head of the dealer
CLAIM BILL
Invoice No/Nos . Date: .
G.C.Note/RRILR No . Date: .
From: . To: .
Name of Surveyor
A. Assessed Amount Rs .
(the amount should be for all the vehicles) <
B. Survey Fee Paid Rs .
C. Total Claim Amount Rs ( A + B)
D. Less: Salvage as assessed by the surveyor Rs .
E. Net Receivable Rs ( C - D)
Date:
Place:
Signature of the claimant
Name:
Designation
Name of the dealership

11. Enclosure A3
Standardfo[mat of Claim Bill
New India Assurance Co.
Claim Bm
Invoice No. 971776690 Date 15/03/2009
GC Note No. 12466 Date 16/03/2009
From Pune To Cochin
Surveyor Mis _
A. Assessed Amount: Rs. 701151.88
B. Survey Fee Paid Rs._2500 __
C. Claim Amount Rs. _703651.88 (A+B)
Salvage as assessed
by surveyor Rs. Not applicable being Total Loss
(Salvage to be deducted only in repair cases)
E .. Net Receivable Rs. 703651.88 (C-O)
Date:
Place: Cochin Signature of Claimant
For Concorde Motors (India) Ltd
Mr. Kamppasamy
Business Unit Head
cochin
----~ _--"''',-----_._--_.
.'~----_ .•.. .....
I<:erala· 682 30<1.
66020101'1'1/'12113
E-i"'fiail . SaLe:;.coc.hm4YCOhcordemotcfS.(;{)ff1, Service.cochrn@concordeTHotors.Gorn. Website: Wvw.concordemotors.com
Ofik" : 3rd Floor, Nanavet! Mahaiaya, 18. Hom, Modi Strl>el. Huatma·Chowk. Mumbai . <100001

12. Monitory Notice on the Transporter to be on the dealers letter head
Ref. No. Date:
To:
Name of the transporter
Full address
Dear Sir,
Sub: Claim for the damage to consignment of
G.C. Note/RRJLR No dated .
Please take Notice that (indicate the no.) vehicles ( cars/MUVs) were
transported from (place) to (place)under your above mentioned G.C.Note/RRJLR No.
___ vehicle(s) out of the same consignment were delivered to us in externally
damaged condition/have not been delivered. Relative GC/RRJLR note has been qualified
to that effect while taking the delivery. The concerned driver of yours has
appended/refuse to append his signature thereto.
Chassis No. Description of damages Amout Repair/Total loss
Please issue immediately, your regular damage certificate. Please also depute your
representative to assess the exact loss as we are also arranging the insurance survey. In
the event of your not deputing your representative simultaneously, the loss assessed by
the Insurance Surveyors, who are Govt. Licensed surveyors, will be finally binding on
you.
Please register our claim for Rs (Total Amount as above )and settle it without any loss of
time.
Thanking you,
Yours sincerely
Name of the dealership,
Signature
Name of the signatory

13. CONCORDE
Passenger Car Dealer
Enclosure A2
Standard Format of Monetary Notice to Transporter
By Regd. Post I Hand Delivery
Ref No. 0001 Date 13/04/2009
To
Klshore Transport Services Pvt. Ltd.
Office 73& 74, Co win c/, 1 st Floor, Purnanaqar Commercial Complex,
Chinchwad, Pune - 19, Tell fax-020-27493234, 27494752153
Sir
Sub: Claim for the damage to consignment of
GC No. 12466 Dated-16/03/2009
Please take Notice that MCA11071709003697CQZvehicie (cars I MUVs) were
transported from Pune to Cochin under your above mentioned GC Note.
12466 vehicle(s) out of the same consignment were delivered to us in externally
damaqed condition / have not been delivered. Relative GC/LR note has been qualified to
that effect while taking the delivery. The concerned driver of yours has appended/refuse
to append his signature thereto.
Damage ---
Amount
Chassis No.
MCA 11071709003697CQZ ~ BODY SHELL DAMAGE
I
!
I 701151.88 ·---1
---1 I
I -----l (TOTAL LOSS) !
Please issue immediately, your regular damage certificate. Please also depute your
representative to assess the exact loss as we are also arranging the insurance survey.
In the event of you not deputing your representative simultaneously, the loss assessed
by the insurance surveyors, who are Govt. licensed surveyors, will be finally binding to
you.
Please register our claim for Rs. Seven lakh One Thousand One Hundred Fiftv One
and settle it without any loss of time.
Thanking you,
Yours truly
For Concorde Motors (India) Ltd
y
Mr. Karuppasamy
Business Unit !lead
Cochin
CC: (Transporter's corporate office)
Insurance Cell, Tata Motors Ltd. Mumbai.
Concorde Motors {India} Limited (100% Subsidiary ofTATA Motors Ltd.)
I: 10, 2561C, Survey No. 156211. Nettoor, Marariu Panchayath, Cachiri, Ernaku!am District. Kerala _ 682 304.
Showroom: Tel: 0484-6602000!01i02103 Service: Tel: 6602010/1'11'12113
[-mail: Saies.ccchin@concordemotors.com.Service.cochill@conCOrdemolors.com.Webslte:wwl.concordemotom.com
Regd. Office: 3rd Floor. Nan3vac Maha!aya. 18. Horr.; "".odl Slreei, Huatma ChOl'/«, Mumbai - 400 001

14. A. K. MATHUR
Insurance Surveyor
SLA-5521
Valid upto 26-02.2012
MARINE SURVEY REOPRT
05.05.09.
To,
The Divisional Manager,
The New India Assurance Co. Ltd.,
Divisional Office,
Pune.
Ref- Transit claim invoice no. 9011088626 dated 21.03.09 from Mis TATA
Motors Ltd. Pune, to Mis Grover Trade Links (P) Ltd., Bareilly. (U.P.)
As pcr request of Grover Trade Links (P) Ltd.,(Auth. Dealer) Bareilly to con-ducl
tbe survey & to assess the loss s1,Jffered by insured due to damages to Tata's Indica
Xeta car bearing Chassis No. 600731BOZP13963 Details of Survev are as follows:-
1. Name of consignor M/S.T.M.L. Distribution Company Ltd.
Pimpri .
Pune.
2. Name of Consignee Mis Gt'over Trade Links {PI Ltd., 4tJ• KM,
Rampur Road, C.B. Ganj, Bareilly.
Bareiny.
3. Name of Insurer The New India Assurance Co. Ltd.,
Pune.
4. Name of Insured Mis T.M.L. Distribution Co. Ltd"
Pune.
5. Name of the Carrier MI s Delhi Gujrat Fleet Carrier,
Shop. No.-48, Jija Mata Market,
Behind HDFC coJony, Shahu Nagar,
MIDC.
Chinch wad,
Pune.
8. Truck No. HR-47-8820.
9. Consignment Note No. 25834 dt 21.03.09.
10. Place of Despatch Pune.
11. Place of Destination BareiUy. (U. P,)
12. Date of Despatch 21.03.09.
13. Date of Delivery 26.03.09.
14. Date of Survey 27.03.09. onwards.
15. Place Survey At the godownl workshop of MI s Grover
Trade links Pvt. Ltd., Bareilly.
Residence: 92, A vas Vikas Colony, Behind Bareilly Club, Hareilly - 243 (){}!
Office: Anand Ashram Complu, Ramplir Garden, Haremy -243(}f)1 (Is, Dr V K Chawla}
Mobile: 9&370 - 53743 Office: 0581-2453248 Resi: 0581·2428505

15. 2 A. K. JYIATHUR
Insurance Surveyor
SLA-5521
Valid upto 26-02.2012
16. Natq.te Goods Carried 3 Nos Tata Indica and 2Nos. TATA Safari
were dispatched in the trailer.
17. Nature of packing The vehicles were dispatched in covered
trailers properly tied/parked in slots
exclusively designed for transportation of
motor vehicles.
18. Nature of loss after
Examination attributed to One No. TATA Indica was damaged from
front portion, damaging front bumper
and sun shade(delivered in damaged
condition from the facLOry).
19. Invoice No. & Date Invoice No. 9011088626 dl. 21.03.09. fO!
Rs.2,69,626.74.
20. Notice To Carrier A Regd. Notice has been given to the
carrier claiming a monitory compensation
ofRs.4000/-.
21. Shortage/Damage Certificate The consignee has obtained a damage
certificate from the driver Shri Mahavir
Singh of truck no. HR-47-8820.
22. Obeservation & findings A consignment of 3 Nos TATA Indica and
2 Nos Tata Safari were booked from Pune
to Barei1ly by road in trailer No. - H]~-47-
8820 vide sale invoice No. 9011088626
dt 21.03.09, c/note no. 25834 dt
21.03.09. During transit due jerks &jolts
the frontal portion of one of the Indica
was bmshed/impacted/damaged and
needed replacements/repairs. The
photographs of the vehicle were arranged
The consignee has obtained a damaged
certificate from the driver, and a Regd.
notice has been served to the transporler
claiming a monitory compensation.
The vehicle was photographed after
repairs/replacements showing the
damaged parts also.
Details of the damaged vehicle
Make TATAIndica.Xeta GLS.
Chassis No. 600731 BQZP13963.
Engine No. 475S158BQZP16201.
Speedo Meter Reading 8.1 Kms.
Reference to policy Since the detailed policy was not made
available therefore no comments on the
same G,ln be made.
Re.~idence: 92, '<"as Vik:" Colony, Behind Bareilly' Club, Bareilly - 243001
Office: Anand Ashram Complex, Rampur Garden, Bar-eilly - 243001 (1St Dr V K Chawla)
Mobile: 98370 - 53743 Office: 058]-2453248 Resi: 058]-2428505

16. A. K. MATHUR
Insurance Surveyor
SLA-5521
Valid upto 26-Q2.2012
SURVEY FEE BLL
05.05.09.
To,
The Divisional Manager,
The New India Assurance Co. Ltd.,
lJiv'isiona! Office,
Pune.
Ref-Transit claim invoice no. 9011088626 dated 21.03.09
M/s TATA Motors Ltd. Pune, to M1s Grover Trade Links
(P) Ltd., Bare illy. (D.P.)
____________ ~~ ~ __ w __ ~ -~--------------------
Survey fee Rs.1500.00
Rs. 200.00
Conveyance Local
Photographs 6 nos. Rs. 90.00
Re-inspection photographs 2 nos: Rs. 30.00
Local Conveyance Rs. 200.00
Total Rs.2020.00
Residl!!!ce: 92, 1V3S Vikas Colouy, .
Officc: Amllld Ashram Complex, Rampn!' Gardc!!, Barcilly 243001 (Is, D" V K Chawla)
Mobile: 98370 53743 Office: 0581-2453248 Rcsi: 0581-2428505

17. Damage certificate to be issued on the letter head of the transporter
To:
Name of the dealer
Address
Sub: Dama2:e certificate without prejudice
Dear Sir.
This is with reference to your monetary notice Ref. No dated received by us.
We do hereby certify purely as witness, that the consignment booked under our GC
Note/RR/LR No dated from to (name of the dealer and location)
at owners risk, subject to the terms and conditions of our carriage has been delivered one
date) to the consignee ..( name of the dealer and the location of the dealership) and
following vehicles got damaged while transit through our car carrier/trailor No ....
Sf. No . description Amount
Yehicle Model
Damage no.
Claim
Chassis
The goods were transported by us at owners risk basis. This certificate of facts is issued
at the specific request of the consignee, solely for the purpose of lodging of their
insurance claim if any with their risk and is without admission of any liabilities
negligence or defaults on our part in regard to any
loss/damage/destruction/leakage/deterioration in transit.
This is strictly without prejudice.
Name of the Transporter
Authorized signatory

18. ---------------~~------ - --- - --- -
SEW
KISHOR TRANSPORT SERViCES PVT. LTDe
DAMAGE CERTIFICATE WITHOUT PREJUDICE
Ref.No. KTSPljDMGTK/09-10/13 Date 18.05.2009
To,
CONCORDE MOTORS,
COCHIN
Dear Sir/Madam1
This is with reference to your monetary notice No. NIL dated 13.04.09
received by us.
We do hereby certify purely as witness1 that the consignment booked under
LR 12466 dt 16.03.09 from Pimpri (Pune) to CONCORDE MOTORS, COCHIN
at owner's risk, subject to the te'rms and conditions of our carriage has been
delivered to the consignee or to their order and following vehicles got
damaged while transit through our car carrier MH18M8678
I BODY SHELL DAMAGE
,
,
LINEA MCA1107170 Claim
Sr. Vehicle Chassis no 701151.88
I Damage Description
9003697CQZ
Amount
11
I
The goods were transported by us at owner1s risk basis. This certificate of
facts is issued at the specific request of the consignee1 solely for the purpose
of lodging of their insurance claim if any with their risk and is without
admission of any liabilities negligence or defaults on our part in regard to any
loss/damage/destruction/leakage/deterioration in transit.
T' . trictly without prejudice.
....••
ll~~.
-,
tl
J-~
S
, ~
ransport Services Pvt. ltd
~tb~r~ignatory
: ..•. 'Q
Corp"taW Offi(e; 3, ijinkya Mansion is! floor, Near Hila, tiya /il1ya Shavan, 32, P.ndita Hamabai Road,MumbaHOO 007.Tel.: 2368 Ion • fax: 2368 0636. '·mail. 9 .kklMYilhoo.-: om
Admn.Offic,,; D 10~. ne Induwial Areo, MiOC, Near london Pilmer. New!, Navi Mumbai· 400 706. Te/.: 2767 0004 i 05. Fax: 2767 0006. Email :kt,plmlJmbai@rediffma,L.-o.n
3riJuch Office-: n/74, !st Floor. C ·'Nlng. POOrf{1 N-dgarCommercia: (ornp1,~x, (hikall RO{jd,M.LO,C.ChiJ')chwud ·4 j 019.1el.: 2/493.234 1) Fin(:2749 3~34 0 (-rTtJ:! kj~ho!pune(~vsnl.lie:.

19. --------------------------------------, ... --------
-."•..
Passenger Cor Dealer
RETAIL INVOICE
Ms. GROVER -TRADE LINK Invoice No : Grover-PB-R-0910-00101
GROVER TRADE LINKS PVT LTD Invoice Date: 07/04/2009
4TH KM, RAMPUR ROAD Model : Indica Xeta GLS
C.B GAr-n, OPP. MINI BYE PASS Chassis No : 600731BQZP 13963
BAREILL Y Kms. :8
BAREILLY 243502 Vehicle Regn. No : AF
Uttar Pradesh India Job Card No. : JC-Grover-PB-0809-006034
Customer TLN No : Job Card Date: 27/03/2009
NC Code; l-GHV5VL Service Request Type: Accident
Customer P.O. No - Date:
Payment Method: CREDIT
U.P.T.TNO ;-BE-0106585 dt. 0110512006 C.S.T. No :- BE-5050795 dt 15/05/2006
TIN No. : 09907601894 SERVICE TAX NO ;- AACCG 3066DSTOOI
Type UoM
~~ Part No/Job Code Particulars Qty Rate(Rs) D~si~ Di5. % VAT % VAT (Rs) Amouat(Ri
I MJ (FR.LHS,SUNSET(PARTNOT PAID
AVAILABLE) )
MI ( FR. BUMPER OIF ) PAID 200.00
MI ( FR.BUMPER PAINTING) PAID 3,060.00
@ 10 % Service Tax : 326.00
@2 % Education Cess: 6.52
@I % S&HE Cess: 3.26
Final Parts In''oice Amount: • 0.00 Final Labour Invoice Amount: 3,595.78
------- -.... - ---- .. ---.----- ---- .•......• ---------------------
.•.
Gross Amount; 3,595.78
Parts Net Taxable Amount: 0,00
Adjustments: 0.22
Rupees Three Thou~andFi"c Hundred Ninet)' Six Only. Grand Total; 3,5%.00
Terms and Conditions: E.&O.E.
I) Goods once sold will not he taken ba<:k.
2) Only the courts of BAREILLY shall have jurisdiction in any proceedings relating to this contmct.
3 I/IVO hereby certify that my/our Registration Certificate under the VXI' Act is in force on the date on which the sale of the goods specified in this bill I cash
memorandum is made by melw and that the transaction of sale cavern! by this bill! cash memomndum has been effected by me/us in the regular course of
my! our business,
VelricIeI Goods received in good condition and to our satisfaction..
For GROVER TRADE LINKS PVT LID
Customer's Signature AutiiOrlsedS'igruuory
Prepared By : MUZAMMIL KHAN Date: 07/04/2009
.. _.a __ __ _ .. _ .. _ .. __ _ .. _ _ _ _ _ _ __ ....•.......
GROVER TRADE LINKS PVT LTD
• GATE PASS •
Customer Name GROVER -TRADE UNK Invoice Ref. :Grover-PB-R-0910-OOtOl dated 07/0412009
Account Name: GROVER TRADE LINKS PVT LTD Invoice Amount: Rs. 3,596.00
Vehicle No : AF
Job Card / Order ref JC-Grover-PB-0809-006034 dated 27/03/2009
Chassis No: 60073IBQZPI3963 Gate Pass No & Date:
Model Name: Indic<t Xeta GLS
Vehicle f Goods received, in good condition and to our satisfaction ..
~:)-
Customer's Signature For GROVER TRADE LINKS PVT LID
4th Km. Rarnpur Road, C. B. Ganj, Bareilly - 243 502 (UP)
Tel:2560667,2560777,2561565,9927500115
e-mail:groverbly@gmail.com

20. (This claim form should be on a plain sheet and as per details below)
THE NEW INDIA ASSURANCE COMPANY LIMITED
MARINE CLAIM FORM
For dispatch of passenger vehicles from the factory premises ofM/s Tata Motors
Limited, Pimpri, Pune.
Name and address of the Consignees
G.C.Note/RRlLR No. and date
Place of destination
Date of receipt of consignment at
final destination
Reasons for delay in delivery, if any
Date on which loss or damage noticed
Nature/quantum ofloss As per nos. of estimate attached
(attach separate detailed estimate) Damaged vehicles totaling Rs. _
Has claim been lodged on Carrier
If not give reasons for it
Was damage certificate obtained from
Carrier? If not, give reason
Remarks, if any
We, the above named, do hereby, to best of our knowledge and belief, warrant the truth
of the foregoing statements in every respect.
Date:
Signature of Claimant
Name
Designation
Name of Dealership

21. The New India Assurance Co.
Marine Claim Form
For dispatch of passenger vehicles from the factory premises of MIs Tata Motors
ltd., Pimpri, pune
:Conconle motors (India) ltd
Name and Address of consignees #l0,256Ic,Survey no. 1562/1nettor nHlnUtI fHlnchuyath,
Coeh in,ernalmlamdist riet j,crala-(,82304
I 12466. 16.03.2009
1 GC Note I LR No. and Date
Cochin
2. Place of Destination
: 06/04/2009
3. Date of receipt of consignment
at final destination
:Due accident - FIR 110-0036)
5. Reasons for delay in delivery if any
:06/04/2009
6. Date on which loss or damage noticed
: As per _i_nos. of estimate
7. Nature/Quantum of loss attached, one per car
(attach separate detailed estimate) Damaged vehicles totaling
Rs ..101J.§1·88
: yes
8. Has claim been lodged on Carrier?
If not, give reasons for it
:Yes
9. Was damage certificate obtained from
Carrier? If not, give reason
:Body SheH Damage (Total Loss)
10. Remarks if any
We, the above named, do hereby, to best of our knowledge and belief, warrant
the truth of the foregoing statements in every respect.
Signature of Claimant
Date: 20/05/2009
For con~ Motors (India)Ltd
Karuppasamy
Business Unit Head
cochin

22. LETTER FOR TOTAL LOS~
Date:20/0512009
To,
The Divisional Manager
New India Assurance Co. Ltd.
Mumbai
Sub: Body Shell Damage (Total Loss)
Dear Sir,
With respect to the below mentioned Chassis No., please note that the vehicle is
beyond repairs as the body shells of this vehicle is damaged. As a result this
cannot be sold as brand new vehicle. In view of this fact, please treat the vehicle
as Total loss.
Name of the Dealer: Concorde Motors (India) Ltd
Name of the Transporter: Kishore Transport Services Pvt. Ltd.
SDM NO. KTSPUDMGTK/09~10/13
Chassis No:- MCA11071709003697CQZ
Thanking You,
Yours W~eIY, Motors
For co~i[o;de India Ltd
Mr. Karuppasamy
Business Unit Head
Cochin

23. Format of letter of subroqation
Letter of Subrogation & Special Power of Attorney
N.S.
Please Affix
Adhesive
Stamp of
Rs.200/- here
before
Signing this
document
THE NEW INDIA ASSURANCE CO. LTD.
DO: 121400, New India Centre,
17/A, Cooperage Road,
Mumbai - 400 039
In consideration of your having paid to us through Tata Motors Ltd., the
consignor, the sum of Rupees ./-
Rupees only in full settlement of
our claim for non-delivery / shortage I damage and theft under Policy No.
.................................... issued by you all on the under mentioned goods, we
hereby assign, transfer and abandon to you all our rights and remedies against
the Railway Administration I Road Transport Carriers or other persons
whatsoever, caused or arising by reason of the said damage or loss and grant
you full power to take and use all lawful ways means in your own name and
otherwise at your risk and expense to recover the claim for the said damage or
loss and we hereby subrogate to you the same rights as we have in
consequence of or arising from the loss or damage.
WHEREAS, the consignor, Mis Tata Motors Ltd. booked the goods under
Invoice nos dated Lorry Receipt. .
dated from Pune to in our name, we hereby appoint, i
nominate constitute THE NEW INDIA ASSURANCE CO. LTD., carrying on i
insurance business, to act by their officer MR. DINESH A. PAl, Sr D.M. and his i
successors as our true and lawful attorneys to do all or any of the following acts, I
deeds and things for us and on our behalf in our name that it to say: -
I
I
1. To receive claim moneys from the Carriers/Motor Transport I
Company or Authorities payable to us under the aforesaid
Invoice/Lorry Receipt.
I
2. To give valid discharge on our behalf pertaining to the above claim.

24. 3. To sign all receipts in our name on our behalf pertaining to the
above claim.
4. To present any applications before any Authority or persons
concerned for claim in respect of aforesaid Invoice/L.R
5. To settle and adjust the above claim, if necessary and to give valid
discharge and effectual receipts.
6. To file suit in court of law against Carrier/Motor Transport
Company, if necessary, for the recovery of the claim money for the
aforesaid claim on our behalf and in our name and give valid
discharge and effectual receipt thereto.
7. To sign, declare, verify and present to courts, such plaints, affidavit
and applications in connection with claim recovery suit filed against
carriers/Motor Transport Company.
We. the said firm , do hereby
ratify and confirm and agree to ratify and confirm all the acts and things
which our said Attorneys shall lawfully do or cause in the done pursuant in
these presents.
IN WITNESS WHEREOF I
MR (designation) Authorised Signatory of the Firm of
M/s for and on behalf of the Firm have set my hand and
Seal aL this day of .
SIGNED SEALED AND DELIVERED
by the within named firm of
M/s.
through the hand of MR (name and designation)
Signature of Consignee
BEFORE ME
NOTARY