DISTRIBUTION COMPANY LIMITEDMUMBAI

ltlARINE CLAIMS

.FAMiLIAR/SA TlON

ON THE!lfAJVDA TOR DOCUME1VT A TIONS

TING EXPEDII10USOF CLAlkfS

BYTIlE lVEW INDIA ASSURANCE C01}1PANY LTD

************************

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 enroutemajor accident)

" .4 letterTotal

toBasis

Subrogation

requesting them to settle the claim on

ofAl/orney ( el."Ie extract of the Board Re,'iwlution )

Covering letter on the Letter head of the dealerThe 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 bearingChassis No/Nos .

Dear Sir,

We forward herewith the following documents in respect of vehicles mentioned above forsubmission to NIA and settlement. Please tick the documents enclosed:

1. Excise Challan - cum -Sales Invoice No dated (original/carbon copy to beenclosed. )

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 original8. Damage Certificate9. Claim Form ( duly filled in and signed - in original)10. Photographs11. 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.

Ref No:

ToInsurance Cell,Tata Motors Ltd.

Passenger Car DivisionWorld Trade Centre, Centre-126m Floor, Cuffe ParadeMumbai 400005

Sub: Ex works Sale Vehicle Marine/Motor Insurance ClaimChassis no(s) MCA11071709003697CQZ

Oate:20/05/2009

Dear SirWe forward herewith the following documents for the purpose of claim undertransit 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 of monetary notice to carrier in originala:rAck. of monetary notice Le. proof of delivery in form of Registered Post AD

yard stamped and signed by the transporter

f3Ypamage Certificate in Original.

~~Iaim Bill in duplicate.19'fiR and Spot survey report if applicable.g' Claim Form in original

~fhotograph and negativesgr Drivers Statement in original & copy of his license.

D Final Repair Bill in original (only for Repair Claims)

~..Repair Estimate in original (for all claims)(i:( Letter of total loss

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. KarpppasamyBusiness Unit l-lead, Cochin

karuppasamyk@concordemotors.com

No. :

Auth.

REMARKS

No·1 46

For Kishor TransportServices Pvt

Kms.

sand di:scrtptio,,'1S interms and conditiorrs of

his agimt who hi." full power and light 10 book tile goods

.~

RVI

him

HO

MIs. TATA MOTORS LTD.Pimpri, Pune - 1 018

Offices

SEV.A

2) The consignor expressly declares that abovebool,5 of account other related documents are in the'ontriilc! which has read and I or explakned and a<X"..apts

• forwarding note, receipts on

1) Received goods enlirel'V at OWNER'S RiSK as delgH" above for carriage end tills ConsJgnmerr! note is Issued~ Contract

ORIGINAl.

90110!3862621.fH.2G09

Shp 00 3835S

BE 0106585 ~T 01.0S.06

BE 5050795 f)T 15.05.06

f.lACCG:!066&

en.

GRI.1IJER TRAf)[ CHileS f' ,M1f{EIlL V

~e.lersPDUeb-GrD~tr-OR09-00/14.

( )Gm.tR TRAOCI..1}Ij(S M LID

4TH I'[I!.ISTM ~ tnll)

[ffl !1INI rrrt PASS I

Gr:IJI.IER11m 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 SeaUI\gC.pwity

"II Drive!'. CololJf : I1etallic MG'r£-,'tIJREi' .

O~si~ Value (Rs.)

lefts Dlscount (Rs.)Subtot.l (Ri>.)

R!)(: (RI>.)

HlHtL (Rs.)

vAT 8 12.5~ nR CST e 1~ (Rs. IGRIIMI> nlTAL Hh.)

2"1;;; 2;'H " 1:3

16.409,[32

::~5S.B2L 318.68')1,00

c!64. ~:;10,31S. 116, 4~j

269.626,74

Driver Report on a plain sheet of paper

DRIVER' REPORT

Name of the Driver(full name as appearing in theDriving licence)

Full Address(As appearing in the driving licence)

Licence Details of the Driver:

Licence No.Date and Place of IssueDate of Expirey

Accident Details

Date and Place of Accident( with District & State)

Transporters name, address andTelephone/mobile No.

Short description of the accidentand the damages sustained to theVehicle/vehicles

Place:Date: (Name of the driver & his signature)

Driver's Report

J"..d..<3lf'rCL O~d;,)7o..{<::'.t:?u..- t-:5C1Pt"tJLcffJ;Yl

, "'l.:::'J:.(. t<,pf.y~l4..."

Df:';X- ~ Eeef!ct)'! ( Ka,.7 v...Jq.l='- ~)

Pvt

.Name of Driver

Address

Transporter's Name & Tel. No.Truck No

: r.{~7

: K (~

Licence's DetailsLicence No.Date & place of issueDate of expiry

Accident DetailsDatePlace of accident

(with District & State)Cause of Accident

Chassis NoEngine NoModel & Colour

!to?( 76 7 Z~: (!)C; ( 6 5"" D g: f ~ •• - ~ .. D1. /V~co1 ~?td

Damage due to the accident

Signature of driver or transport contractor

GWNDfrA(Name: 63tJw,~l)

Date: 4'.

ONCORDE

PassengerCarDea~r

136 WHEEL DISC 2500I

.lITYRE WITH TUBE

38<KNl!~KLE BEARING

6600---3!J REAR ARM WIIH HUB __ -2l.t!Q-«-«1-. «----40iREAR DISC 1500

4~<IREAf{ SHOCK f,SSY1951

42 'RbAR SPf<lNt; ASSY

540

43 RH REAR ODOR

500-~ -<-----. <-

44<REA~<B<~1£..ERA~.§.L_.< ___ • 400-.----.----< 3500

5000- ..--------~45 REAR BUMPEI~ GARNISH RH

1940

46 REAR BUMPER GARNISH LH

1940

471TAIl U\MP lH

I 2325

4BITAIL LAMP RH

I 2325491ROOF SEEDING 2 NO.S

I 1744

~2J.!:MOT'ON_ EMBl£I:1. __ «_ f--------=:;l,,57!) --j--",I FIAT EMBLEM

7.00,f~OO-645

52 iLINEA EMBLEM: 507[

53 FRONT WIS GLASS R&R

1500[ I54 DASH BOP.HO ASSY R&R

9001 IJ~_5

EtJ_GINE R&R _1500'

~j----!=-----~

5IJ

NC GAS _ 1~~. _____..-.,--,-

--~._.---"'.--,.57 ~~~AT & ELEC!'.BICAI._ ---~-----_.r-~ 58

FRONT SUSPENSION !59

\'''' I£:EL ALIGNMENT 500160 FRT GRiLL

1 5781Total:

46900 210041685166000IGrand Totar :

531851 I..

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 \••.o.-x involved

3 Taxes will hi-: Axtra & willtJe indudAr! in the final hi!! of repairs4 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:J11-1

!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

Rfl£.;t:LOfhcf: . 3rd FeeL ;"~3naV.1~:M8 -;f1:?Y~ 13. H,.Y:ii M!)d; S:reet, i-tua~ma·Ci1Cwk. t••1umbal· 400 001if

On the letter head of the dealer

CLAIM BILL

Invoice No/Nos .

G.C.Note/RRILR No .

From: .

Name of Surveyor

A. Assessed Amount

(the amount should be for all the vehicles)<

B. Survey Fee Paid

C. Total Claim Amount

D. Less: Salvage as assessed by the surveyor

E. Net Receivable

Date:Place:

Date: .

Date: .

To: .

Rs .

Rs .

Rs ( A + B)

Rs .

Rs ( C - D)

Signature of the claimant

Name:

DesignationName of the dealership

Enclosure A3

Standardfo[mat of Claim Bill

New India Assurance Co.

Claim Bm

Invoice No. 971776690 Date 15/03/2009

GC Note No.

From Pune

12466

To

Date 16/03/2009

Cochin

Surveyor Mis _

A.B.

C.

Assessed Amount:

Survey Fee Paid

Claim Amount

Salvage as assessedby surveyor

Rs. 701151.88

Rs._2500 __

Rs. _703651.88 (A+B)

Rs. Not applicable being Total Loss(Salvage to be deducted only in repair cases)

E .. Net Receivable

Date:

Place: Cochin

Rs. 703651.88

Signature of Claimant

(C-O)

For Concorde Motors (India) Ltd

Mr. KamppasamyBusiness Unit Headcochin

----~.•...'~----_....._--"''',-----_._--_.

I<:erala· 682 30<1.

66020101'1'1/'12113

E-i"'fiail . SaLe:;.coc.hm4YCOhcordemotcfS.(;{)ff1, Service.cochrn@concordeTHotors.Gorn. Website: W\vw.concordemotors.com

Ofik" : 3rd Floor, Nanavet! Mahaiaya, 18. Hom, Modi Strl>el. Huatma·Chowk. Mumbai . <100001

Ref. No.

Monitory Notice on the Transporter to be on the dealers letter head

Date:

To:

Name of the transporterFull address

Dear Sir,

Sub: Claim for the damage to consignment ofG.C. Note/RRJLR No dated .

Please take Notice that (indicate the no.) vehicles ( cars/MUVs) weretransported 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 externallydamaged condition/have not been delivered. Relative GC/RRJLR note has been qualifiedto that effect while taking the delivery. The concerned driver of yours hasappended/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 yourrepresentative to assess the exact loss as we are also arranging the insurance survey. Inthe event of your not deputing your representative simultaneously, the loss assessed bythe Insurance Surveyors, who are Govt. Licensed surveyors, will be finally binding onyou.

Please register our claim for Rs (Total Amount as above )and settle it without any loss oftime.

Thanking you,

Yours sincerelyName of the dealership,SignatureName of the signatory

CONCORDE

Passenger Car Dealer

Enclosure A2Standard Format of Monetary Notice to Transporter

Ref No. 0001

By Regd. Post I Hand Delivery

Date 13/04/2009

ToKlshore 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 ofGC No. 12466 Dated-16/03/2009

Please take Notice that MCA11071709003697CQZvehicie (cars I MUVs) weretransported from Pune to Cochin under your above mentioned GC Note.

12466 vehicle(s) out of the same consignment were delivered to us in externallydamaqed condition / have not been delivered. Relative GC/LR note has been qualified tothat effect while taking the delivery. The concerned driver of yours has appended/refuseto append his signature thereto.

Chassis No. ~MCA 11071709003697CQZ I!

I -----l

DamageBODY SHELL DAMAGE I

(TOTAL LOSS) !

Amount---701151.88 ·---1---1

I

Please issue immediately, your regular damage certificate. Please also depute yourrepresentative 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 assessedby the insurance surveyors, who are Govt. licensed surveyors, will be finally binding toyou.

Please register our claim for Rs. Seven lakh One Thousand One Hundred Fiftv Oneand settle it without any loss of time.

Thanking you,

Yours truly

For Concorde Motors (India) Ltd

yMr. KaruppasamyBusiness Unit !leadCochin

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:w\wl.concordemotom.com

Regd. Office: 3rd Floor. Nan3vac Maha!aya. 18. Horr.; "".odl Slreei, Huatma ChOl'/«, Mumbai - 400 001

A. K. MATHURInsurance Surveyor

SLA-5521

Valid upto 26-02.2012

MARINE SURVEY REOPRT05.05.09.

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 TATAMotors 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-ducltbe survey & to assess the loss s1,Jffered by insured due to damages to Tata's IndicaXeta car bearing Chassis No. 600731BOZP13963 Details of Survev are as follows:-

1. Name of consignor

2. Name of Consignee

3. Name of Insurer

4. Name of Insured

5. Name of the Carrier

8. Truck No.

9. Consignment Note No.

10. Place of Despatch

11. Place of Destination

12. Date of Despatch

13. Date of Delivery

14. Date of Survey

15. Place Survey

M/S.T.M.L. Distribution Company Ltd.Pimpri .Pune.

Mis Gt'over Trade Links {PILtd., 4tJ• KM,Rampur Road, C.B. Ganj, Bareilly.Bareiny.

The New India Assurance Co. Ltd.,Pune.

Mis T.M.L. Distribution Co. Ltd"Pune.

MI s Delhi Gujrat Fleet Carrier,Shop. No.-48, Jija Mata Market,Behind HDFC coJony, Shahu Nagar,MIDC.Chinch wad,Pune.

HR-47-8820.

25834 dt 21.03.09.

Pune.

BareiUy. (U. P,)

21.03.09.

26.03.09.

27.03.09. onwards.

At the godownl workshop of MI s GroverTrade links Pvt. Ltd., Bareilly.

Residence: 92, Avas 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

16. Natq.te Goods Carried

17. Nature of packing

18. Nature of loss afterExamination attributed to

19. Invoice No. & Date

20. Notice To Carrier

21. Shortage/Damage Certificate

2 A. K. JYIATHURInsurance Surveyor

SLA-5521Valid upto 26-02.2012

3 Nos Tata Indica and 2Nos. TATASafariwere dispatched in the trailer.

The vehicles were dispatched in coveredtrailers properly tied/parked in slotsexclusively designed for transportation ofmotor vehicles.

One No. TATA Indica was damaged fromfront portion, damaging front bumperand sun shade(delivered in damagedcondition from the facLOry).

Invoice No. 9011088626 dl. 21.03.09. fO!Rs.2,69,626.74.

A Regd. Notice has been given to thecarrier claiming a monitory compensationofRs.4000/-.

The consignee has obtained a damagecertificate from the driver Shri MahavirSingh of truck no. HR-47-8820.

22. Obeservation & findings

Details of the damaged vehicle

MakeChassis No.Engine No.Speedo Meter Reading

Reference to policy

A consignment of 3 Nos TATA Indica and2 Nos Tata Safari were booked from Puneto Barei1ly by road in trailer No. - H]~-47­8820 vide sale invoice No. 9011088626dt 21.03.09, c/note no. 25834 dt21.03.09. During transit due jerks &joltsthe frontal portion of one of the Indicawas bmshed/impacted/damaged andneeded replacements/repairs. Thephotographs of the vehicle were arrangedThe consignee has obtained a damagedcertificate from the driver, and a Regd.notice has been served to the transporlerclaiming a monitory compensation.The vehicle was photographed afterrepairs/replacements showing thedamaged parts also.

TATAIndica.Xeta GLS.600731 BQZP13963.475S158BQZP16201.8.1 Kms.

Since the detailed policy was not madeavailable therefore no comments on thesame G,ln be made.

Re.~idence: 92, '<\"as Vik:" Colony, Behind Bareilly' Club, Bareilly - 243001Office: Anand Ashram Complex, Rampur Garden, Bar-eilly - 243001 (1St Dr V K Chawla)

Mobile: 98370 - 53743 Office: 058]-2453248 Resi: 058]-2428505

A. K. MATHURInsurance Surveyor

SLA-5521Valid upto 26-Q2.2012

SURVEY FEE BLL05.05.09.

To,The Divisional Manager,The New India Assurance Co. Ltd.,lJiv'isiona! Office,Pune.

Ref-Transit claim invoice no. 9011088626 dated 21.03.09M/s TATA Motors Ltd. Pune, to M1s Grover Trade Links(P) Ltd., Bare illy. (D.P.)

____________ ~~ ~ __ w __ ~ -~--------------------

Survey fee

Conveyance Local

Rs.1500.00

Rs. 200.00

Photographs 6 nos. Rs. 90.00

Re-inspection photographs 2 nos: Rs. 30.00

Local Conveyance

Total

Rs. 200.00

Rs.2020.00

Residl!!!ce: 92, 1\V3S Vikas Colouy, .Officc: Amllld Ashram Complex, Rampn!' Gardc!!, Barcilly 243001 (Is, D" V K Chawla)

Mobile: 98370 53743 Office: 0581-2453248 Rcsi: 0581-2428505

Damage certificate to be issued on the letter head of the transporter

To:Name of the dealerAddress

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 GCNote/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 onedate) to the consignee ..( name of the dealer and the location of the dealership) andfollowing vehicles got damaged while transit through our car carrier/trailor No ....

Sf. No . Yehicle ModelChassis no.DamageClaim Amount. description

The goods were transported by us at owners risk basis. This certificate of facts is issuedat the specific request of the consignee, solely for theinsurance claim if any with their risk and is withoutnegligence or defaults on our partloss/damage/destruction/leakage/deterioration in transit.

This is strictly without prejudice.

Name of the Transporter

Authorized signatory

purpose of lodging of theiradmission of any liabilitiesin regard to any

---------------~~------ - --- - --- -

SEW\

KISHOR TRANSPORT SERViCES PVT. LTDe

DAMAGE CERTIFICATE WITHOUT PREJUDICE

Ref.No. KTSPljDMGTK/09-10/13

To,CONCORDE MOTORS,COCHIN

Date 18.05.2009

Dear Sir/Madam1

This is with reference to your monetary notice No. NIL dated 13.04.09received by us.

We do hereby certify purely as witness1 that the consignment booked underLR 12466 dt 16.03.09 from Pimpri (Pune) to CONCORDE MOTORS, COCHINat owner's risk, subject to the te'rms and conditions of our carriage has beendelivered to the consignee or to their order and following vehicles gotdamaged while transit through our car carrier MH18M8678

Sr. Vehicle Chassis noDamage DescriptionClaimIModel

AmountI-- ,

I

MCA110717011

LINEA9003697CQZBODY SHELL DAMAGE701151.88

I

,

The goods were transported by us at owner1s risk basis. This certificate offacts is issued at the specific request of the consignee1 solely for the purposeof lodging of their insurance claim if any with their risk and is withoutadmission of any liabilities negligence or defaults on our part in regard to anyloss/damage/destruction/leakage/deterioration in transit.

T' . trictly without prejudice.tl S

J-~ ransport Services Pvt. ltd....•• -, ,~

ll~~.~tb~r~ignatory

\: ..•. 'Q

Corp"taW Offi(e; 3, i\jinkya 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 (-rT\tJ:! kj~ho!pune(~vsnl.lie:.

--------------------------------------, ... -."•..--------Passenger Cor Dealer

RETAIL INVOICE

MI

MI

Invoice No : Grover-PB-R-0910-00101Invoice Date: 07/04/2009Model : Indica Xeta GLSChassis No : 600731BQZP 13963Kms. :8

Vehicle Regn. No : AFJob Card No. : JC-Grover-PB-0809-006034Job Card Date: 27/03/2009

Service Request Type: AccidentCustomer P.O. No - Date:

Payment Method: CREDIT

C.S.T. No :- BE-5050795 dt 15/05/2006

SERVICE TAX NO ;- AACCG 3066DSTOOI

Qty Rate(Rs) D~si~ Di5. % VAT % VAT(Rs) Amouat(Ri

Ms. GROVER -TRADE LINKGROVER TRADE LINKS PVT LTD

4TH KM, RAMPUR ROADC.B GAr-n, OPP. MINI BYE PASSBAREILL YBAREILLY 243502Uttar Pradesh IndiaCustomer TLNNo :NC Code; l-GHV5VL

U.P.T.TNO ;-BE-0106585 dt. 0110512006

TIN No. : 09907601894

~~ Part No/Job Code ParticularsI MJ (FR.LHS,SUNSET(PARTNOT

AVAILABLE) )

( FR. BUMPER OIF )

( FR.BUMPER PAINTING)

Final Parts In''oice Amount:

Type

PAID

PAID

PAID

UoM

• 0.00

@ 10 % Service Tax :@ 2 % Education Cess:@ I % S&HE Cess:Final Labour Invoice Amount:

200.00

3,060.00

326.006.523.26

3,595.78

Parts Net Taxable Amount: 0,00

Rupees Three Thou~andFi"c Hundred Ninet)' Six Only.Terms and Conditions:

------- -.... -.•. ---- ..---.----- ---- .•......• ---------------------Gross Amount; 3,595.78

Adjustments: 0.22

Grand Total; 3,5%.00

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 ofmy! our business,

VelricIeI Goods received in good condition and to our satisfaction..

For GROVER TRADE LINKS PVT LID

Customer's Signature

Prepared By : MUZAMMIL KHAN

AutiiOrlsedS'igruuory

Date: 07/04/2009

.. _.a __ __ _ .. _ .. _ .. __ _ .. _ _ _ _ _ _ __ ....•.......

Customer Name GROVER -TRADE UNKAccount Name: GROVER TRADE LINKS PVT LTDVehicle No : AF

Chassis No: 60073IBQZPI3963Model Name: Indic<tXeta GLS

Vehicle f Goods received, in good condition and to our satisfaction ..

Customer's Signature

GROVER TRADE LINKS PVT LTD

• GATE PASS •

Invoice Ref. :Grover-PB-R-0910-OOtOl dated 07/0412009

Invoice Amount: Rs. 3,596.00

Job Card / Order ref JC-Grover-PB-0809-006034 dated 27/03/2009Gate Pass No & Date:

\~:)\\-For GROVER TRADE LINKS PVT LID

4th Km. Rarnpur Road, C. B.Ganj, Bareilly - 243 502 (UP)Tel:2560667,2560777,2561565,9927500115e-mail:groverbly@gmail.com

(This claim form should be on a plain sheet and as per details below)

THE NEW INDIA ASSURANCE COMPANY LIMITEDMARINE CLAIM FORM

For dispatch of passenger vehicles from the factory premises ofM/s Tata MotorsLimited, Pimpri, Pune.

Name and address of the Consignees

G.C.Note/RRlLR No. and date

Place of destination

Date of receipt of consignment atfinal destination

Reasons for delay in delivery, if any

Date on which loss or damage noticed

Nature/quantum ofloss(attach separate detailed estimate)

Has claim been lodged on CarrierIf not give reasons for it

Was damage certificate obtained fromCarrier? If not, give reason

Remarks, if any

As per nos. of estimate attachedDamaged vehicles totaling Rs. _

We, the above named, do hereby, to best of our knowledge and belief, warrant the truthof the foregoing statements in every respect.

Date:

Signature of Claimant

Name

DesignationName of Dealership

The New India Assurance Co.Marine Claim Form

For dispatch of passenger vehicles from the factory premises of MIs Tata Motorsltd., Pimpri, pune

Name and Address of consignees

I1 GC Note I LR No. and Date

2. Place of Destination

3. Date of receipt of consignmentat final destination

5. Reasons for delay in delivery if any

:Conconle motors (India) ltd#l0,256Ic,Survey no. 1562/1nettor nHln\UtI fHlnchuyath,Coeh in,ernalmlamdist riet j,crala-(,82304

12466. 16.03.2009

Cochin

: 06/04/2009

:Due accident - FIR 110-0036)

6. Date on which loss or damage noticed

7. Nature/Quantum of loss(attach separate detailed estimate)

8. Has claim been lodged on Carrier?If not, give reasons for it

9. Was damage certificate obtained fromCarrier? If not, give reason

10. Remarks if any

:06/04/2009

: As per _i_nos. of estimateattached, one per carDamaged vehicles totalingRs ..101J.§1·88

: yes

:Yes

:Body SheH Damage (Total Loss)

We, the above named, do hereby, to best of our knowledge and belief, warrantthe truth of the foregoing statements in every respect.

Date: 20/05/2009 Signature of Claimant

For con~ Motors (India)LtdKaruppasamyBusiness Unit Headcochin

LETTER FOR TOTAL LOS~

Date:20/0512009To,The Divisional ManagerNew 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 isbeyond repairs as the body shells of this vehicle is damaged. As a result thiscannot be sold as brand new vehicle. In view of this fact, please treat the vehicleas 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,For co~i[o;de Motors India LtdMr. KaruppasamyBusiness Unit HeadCochin

Format of letter of subroqation

Letter of Subrogation & Special Power of Attorney

N.S.Please AffixAdhesiveStamp of

Rs.200/- herebefore

Signing thisdocument

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., theconsignor, the sum of Rupees ./-Rupees only in full settlement ofour claim for non-delivery / shortage I damage and theft under Policy No..................................... issued by you all on the under mentioned goods, wehereby assign, transfer and abandon to you all our rights and remedies againstthe Railway Administration I Road Transport Carriers or other personswhatsoever, caused or arising by reason of the said damage or loss and grantyou full power to take and use all lawful ways means in your own name andotherwise at your risk and expense to recover the claim for the said damage orloss and we hereby subrogate to you the same rights as we have inconsequence of or arising from the loss or damage.

WHEREAS, the consignor, Mis Tata Motors Ltd. booked the goods underInvoice nos dated Lorry Receipt. .dated from Pune to in our name, we hereby appoint,nominate constitute THE NEW INDIA ASSURANCE CO. LTD., carrying oninsurance business, to act by their officer MR. DINESH A. PAl, Sr D.M. and hissuccessors as our true and lawful attorneys to do all or any of the following acts,deeds and things for us and on our behalf in our name that it to say: -

1. To receive claim moneys from the Carriers/Motor TransportCompany or Authorities payable to us under the aforesaidInvoice/Lorry Receipt.

2. To give valid discharge on our behalf pertaining to the above claim.

iiiI

\III

I

3. To sign all receipts in our name on our behalf pertaining to theabove claim.

4. To present any applications before any Authority or personsconcerned for claim in respect of aforesaid Invoice/L.R

5. To settle and adjust the above claim, if necessary and to give validdischarge and effectual receipts.

6. To file suit in court of law against Carrier/Motor TransportCompany, if necessary, for the recovery of the claim money for theaforesaid claim on our behalf and in our name and give validdischarge and effectual receipt thereto.

7. To sign, declare, verify and present to courts, such plaints, affidavitand applications in connection with claim recovery suit filed againstcarriers/Motor Transport Company.

We. the said firm , do herebyratify and confirm and agree to ratify and confirm all the acts and thingswhich our said Attorneys shall lawfully do or cause in the done pursuant inthese presents.

IN WITNESS WHEREOF IMR (designation) Authorised Signatory of the Firm ofM/s for and on behalf of the Firm have set my hand andSeal aL this day of .

SIGNED SEALED AND DELIVEREDby the within named firm ofM/s.

through the hand of MR (name and designation)Signature of Consignee

BEFORE ME

NOTARY