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Break-In Insurance Inspection Report

This document is an insurance inspection report for a private car following a break-in. It details the vehicle information, owner information, inspection date and place. It provides a thorough checklist of the car's exterior and interior components and notes the condition of each (e.g. safe, scratched, pressed, broken etc.). It also documents the vehicle's previous insurance details and proposed insurance status of the registered owner. The owner declares that the vehicle details and damage noted are correct and that the vehicle was not involved in an accident since the previous insurance expired.

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Yogesh Patil
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571 views1 page

Break-In Insurance Inspection Report

This document is an insurance inspection report for a private car following a break-in. It details the vehicle information, owner information, inspection date and place. It provides a thorough checklist of the car's exterior and interior components and notes the condition of each (e.g. safe, scratched, pressed, broken etc.). It also documents the vehicle's previous insurance details and proposed insurance status of the registered owner. The owner declares that the vehicle details and damage noted are correct and that the vehicle was not involved in an accident since the previous insurance expired.

Uploaded by

Yogesh Patil
Copyright
© All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
  • Break-In Insurance Inspection Report – Private Car

Break- In Insurance Inspection Report – Private Car

Name of Car Owner:- …………………………….………….. Vehicle No:-


Address …………………………………
Requesting Dealer….SIMRAN MOTORS…. Contact No - ………………..……………..………….
Inspection Date ……………………………………
Time ….…………..…….. Place……………….……...
Insurable YES / NO

Safe Scratch Pressed Broken Whether Old policy was M I Policy


Front Bumper Chassis No.:
Grill Engine No.:
Head Lamp (LT / RT) Make/Model:
Side Turn Light (LT / RT) Colour:
Indicator Light (LT / RT) Year of manufacture:
Fog Lamp (LT / RT) Odometer Reading: KM
Front Panel Fuel Used: Diesel / Petrol / CNG
Bonnet Accessories
Left Apron (Electrical)

Right Apron Stereo/Make


LT Fender CD Changer / Make
LT Front Door Any Other
LT Rear Door (Non Electrical)
LT Pillar Front (A) Seat Covers
LT Pillar Centre (B) Centre Locking
LT Pillar Rear (C) Any Other
LT Running Board (Glasses)
LT Qtr. Panel Safe Broken
Dicky Front Wind Shield Glass
Rear Bumper Left Front Door Glass
Tail Lamp (LT/RT) Left Rear Door Glass
RT Qtr. Panel Right Front Door Glass
RT Rear Door Right Rear Door Glass
RT Front Door Rear W.S. Glass
RT Pillar Front (A) Previous Insurance Details:
RT Center Pillar(B) Name of the Insurer:
RT Pillar Rear (C) Policy No.
RT Running Board Expiry
RT Fender No. of Claim
Floor / Silencer Time Lapse
Rear View Mirror (LT/RT) [Link]: Yes/No.
Tyres / Rim Proposed insured is Reg. Owner: Yes/No.

Remarks..................................................................................................................................................................,
Declaration of owner
I hereby confirm and declare that above mentioned identification details of my vehicle No._________________________ as well as
that of damage to the vehicle as noted by the inspecting official are correct. Nothing has been hidden/undisclosed.
I further confirm & declare that the Motor vehicle proposed for insurance after a break in cover has not met with any accident giving rise to
any claim by a Third Party for injury or death caused to any person or damages to any property/Insured vehicle during the period following
the expiry of a previous insurance, till the moment it is proposed for insurance.
I also agree that damages mentioned above shall be excluded/ adjusted in the event of any claim being lodged.

Name & Sign of Proposer …………………….


AGENCY SIGNATURE
Name & Sign of Inspecting Officer ……………………………….
(Authorized signatory)

Break- In Insurance Inspection Report – Private Car Name of Car Owner:- …………………………….………….. Vehicle

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