Saturday, December 18, 2010

Machinery Breakdown survey report format

Surveyor Ref:

Date:


MACHINERY BREAK DOWN – SURVEY REPORT              
(This report is issued with out prejudice in respect of cause nature and extent of loss / damage and subject to the terms and conditions of the Insurance policy.)



INSURANCE POLICY
PARTICULARS
Name of the insurer
:


Name of the insured
:


Policy number
:

Period of insurance

:

Type of policy

:
Machinery break down

Premises / works address

:


Item insured as per policy

:

Total sum insured

:

Total premium charged

:

Failed item covered in policy

:
Schedule serial number :

Sum insured for failed machine

:

Initial policy excess

:


BREAK DOWN
DETAILS
Date of break down
:

Time of break down
:

Witness of the occurrence
:

Place of occurrence

:


Repair work attended by

:


Amount claimed by the insured

:


SURVEY PARTICULARS
Survey work appointed by
:

Date of appointment
:

Date of survey
:

Place of survey

:

Person present during survey

:


DETAILS OF FAILED UNIT
Purchase invoice particulars
:

Details of guarantee period
:

Function of the machine
:

Details of log book

:

Name plate details

:

Details of damage

:





INSURABLE
 INTREST


      On verification of records produced by the insured, I came to know that the said failed Machine was owned by the insured and hence the insured has insurable interest in the here mentioned machine.

                                   
ADEQUACY OF
SUM INSURED
Insured value of the machine failed machine
:
Rs.
Present cost of the new machine
:
Rs.
New machine quotation received from
:
M/s.


Remarks

:

           
ABOUT THE
RISK





It was informed that there was no major loss / damage in the past.
The said machine is operated and maintained as per the recommendation of OE manufacture. 

CAUSE
OF LOSS






LOSS ASSESSMENT

The sudden, unforeseen physical loss / damage to the insured property had occurred during the period of insurance and due to a peril not excluded in the policy.

There is no breach of warranty nor willful act / negligence on the part of insured. Hence, in my opinion the claim is admissible.


I have given below my assessment.
SL No
Particulars
Qty
Estimate
Assessed





 





 





 





 





 





 





 





 





 








SURVEYOR COMMENTS
Serial number of the failed machine was verified physically and found in order with policy copy.
The sum insured for the damaged property is adequate / Not adequate
Depreciation :
Salvage value :


In my opinion amount payable to the insured is Rs. ………………..
I have received the claim papers from the insured on …………………
The repaired unit was inspected by me on ………………… .
Copy of invoice and payment details were collected and enclosed for your reference.


SIGNATURE







.          


ENCLOSURES
Survey bill
Photos taken by me        Nos.
Claim intimation letter
Claim form
Estimate
Policy copy
Witness statement
New machine quotation–to check adequacy of insurance
Final bill with payment details
Test report after completion of repair work.


2 comments:

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