To

Mr. Rajesh
Gawandi
Motor
Investigation
Team
BAJAJ General
Insurance
Company Ltd,
Please accept
our thanks on
having
entrusted ICS
Assure Services Pvt Ltd to assist you in your ongoing endeavor of
rational management of claims.
At this juncture, we would like to reiterate that this Report is being
issued strictly Without Prejudice, Strictly Confidential and ONLY for
the purpose of the BAJAJ General Insurance Co. Ltd. claims
settlement process.
Thanking you,
Yours truly
Dr Satish Kanojia
Manager Claims
29.08.2016

Verification
Report
Claim no

OC-17-20011801-00005611

Policy No

OG-16-17171801-00010634

Date and Time

of Loss

13-Jun-16
@
Between 12:00
To 12:15 AM

Claim referral to
investigation

27/07/2016

Claim Intimation TAT

27 Days (Insured was not available for first

few days, IV driver (Insureds husband) was
out of India and no one was available to
confirm the loss location)

Name of insured

Mrs. Mohini Chavan

Profile of Insured

Insured is housewife, Insured husband is

working in merchant navy.

Address:

53/1, Indraprastha, Matye Daabolim Chicalim,

Vaso-Da-Gama, South Goa.

Contact person and Contact

No

9960565252

Policy details

OG-16-1717-1801-00010634

policy type

Private Vehicle Policy.

Policy Period

From: 19-JAN-2016 To 8-JAN-2017

RC Details :
RC is not
provided by the
Insureds wife as
she does not
have any
documents with
her.

License of the Driver :

Mr. Vikrant
Chavan
Fl No:06 Surekha
Enclave Near
Shivsagar Apts,
Mangor Hill, Vasco,
Goa
GA-06-R-20070075974
MCWGR
LMV-NT
MCWGR: 07-062005
LMV-NT: 07-062005

Driver Name
Address

DL.No.
Authorized To Drive
D.O.I.

DL Validity

SN Occupants Name and

Details.
01 Mr. Vikrant Chavhan
02 Mrs. Mohini Chavhan

06/06/2025 (NT)

Injury Detail
No Injuries
No Injuries

Our
Sr
N
01

Relationship with
insured.
Insureds Husband
(Driver)
Insured.

Field Officer Visits and Meeting with Description.

Visits, Meetings and Other
Description
Information
Police station.
Insured has not lodge any
police complaint.However we
have visited the Vadgaon
police station but no complaint
has been register for the said
accident
02 Vehicle Visit:
We visited the IV and took
photograph of the IV.IV is in the
Atul Motors.

03

Insureds
Visit

We have visited
the Insured and
procured his
written
statement.

04

Driver:

05

Occupant
Visit

06

Eye
Witness

08

Workshop Visit :

Insured
husband was
driving the IV at
the time of
accident. He is
out of India.
Insured and her
husband were
only 2 persons
were in the IV at
the time of
accident.
We have meet
the family whose house is near
to the loss location they
confirmed the accident.
Mr. Tanaji: 09890093413
Mr. Santosh: 7757956779
We have visited the workshop
and procured the security
register entry.

IV reported to
workshop on
14/06/2016.

Claim Form Statement

10

11

Statement of the
IV driver
(Insureds
Husband) Mr.
Vikrant Chavhan:
Mr. Vikrant is out
of India, We have
procured his
statement via his
Email:

Vicky_ksm@yahoo.co.in
Hi Mr. Patil,
Reply to your above questionnaire,
Ans.1. Myself (Vikrant J Chavan) was driving the vehicle, and my wife was sitting in the front
left sit ( Mohini V Chavan).
Ans.2. Both husband and wife.
Ans.3. It was a regular trip from Goa to Baramati started at 4 pm, its was our normal journey of 7
to 8 hours, approximate ETA to our destination was around 11.30 pm,
we had sandwich and tea at our regular hotel stop at the pune - banglore highway at round 8 pm,
and proceeded our further journey and the next stop was at satara - lonand bypass , i had my tea,
at around 10.30 pm, and we started from there it takes about 1 to one and half hour to vadgaonnimbalkar, my in laws place,
reached nira by 11.40 from there its just half and hour drive if no bullock carts carrying
sugarcane,just 2 to 4 kms before our destination on a slight turn vehicle was coming in the wrong
direction and suddenly try to come on the road to its right direction to avoid direct collision i
tried to go on my wrong side to my right it was in a split second i lost my steering control and
hit the mile stone and then a big tree, when the SUV hit the mile stone both the airbags came off i
could not see in front, my wife had just got up with the sudden jerk ,as she might have fall
asleep, she was awake all the time through out,i pulled the hand brakes as the vehicle stared
coming in reverse after it hit the tree,she was just in a shock,luckily we both did not get hurt not
even a scratch, as we both were having our sit belts on.the other vehicle just left did not even
stop to see what happened,
accident took place on 13th june at around 12.00 to 12.15 in the night.
Ans.4. please see the attach file.
Ans.5. journey started from my home in Dabolim (GOA) to my in laws place Vadgaonnimbalkar (tal - Baramati) we started at 4pm in the evening, we were going for the preparation of
our Ganesh mandir 2nd anniversary pooja, and our visit to our on going project at vadgaon
nimbalkar,
Ans.6. the speed of the vehicle was around 70 kmph at the time of the accident, i have been
driving on this road for the past eleven years and with my outlander for the last six years.
Ans.7. i was fully conscious, but my wife was in a shock, my side door was open as it was hit
and we both got out from the driver side.
Ans.8. It was my be our Ganesh kurpa we did not even get a scratch, only my wife was in a
shock for a while.
Ans.9. no injuries.
12

Ans.10. i called my
father in law first his
number 9860348144.
(M D Rajabhau
RajeNimbalkar)
Ans.11. my father in
law called his
younger son inlaw
from baramati , told
him to get the towing
crane from baramati
and the vehicle was
towed to pune on the
same night.
Ans.12. I told him to
take it to the Mitsubishi service station in pune (Petkar Motors).all entry is in there in the register
when the vehicle was brought to the service station date and time.
Ans.13.my father in law called the crane from baramati.at the same time on the same day of the
accident at night.
Ans.14.My original license, vehicle registration book,insurance policy everything is with Petkar
motors its with Mr. Hanif you can take it from him.
Ans.15. please see the attach file.
Ans.16. please see the attach file.
I have provide you with what ever information you have asked for,
would appreciate if the claim of insurance is provided at the earliest.
i am a seamen travelling round the world and not working in oman.
Thanking you ,
Regards,
Vikrant Chavan.
Insureds Statement:

13

14

15

Key Points
from the
Insureds
Statement:
On 13 June 2016
I was traveliing
with my husband
from Goa in our
outlander.
I was sitting on
the front left side
seat and my
husband was
driving the car.
We started the journy at 04:00 PM and expected to reach my fathers palce
Vadgaon nimbalkar around 12:30 PM.
Though I was sitting on left seat and the road was almost empty. I had just
closed my eyes when the car turned right with the jerk and the air bags
came out.
Both of us did not sustain any Injuries.

16

17

Key Points:
On date
13/06/2016
night around
12:00 AM to
12:30 AM I get
call from my
brother in law
Mr. Vikrant
abut the
accident. I
immideately go
to the accident
spot which is
around 2 KM before the Vadgav Nimbalkar village.

Loss Location Analysis:

Image 1:

18

Red Arrow shows the direction of the IV. Yellow arrow depicts the direction when it goes off
road and dashed to the milestone.

19

20

21

22

Accident Spot
provided by the
Insured:

23

IV damaged analysis:

24

Image 1:

25

26

Image 3:

27

Both air bags has been deployed of the IV.Interior of the IV does not sustain any damages.
Observation :
Damages sustain by the IV are co relating with the accident spot and the
cause of accident and statement of the Insured.
As per the driver statement, On date 13/06/2016 night 12:00 AM on a
slight turn vehicle was coming in the wrong direction and suddenly try to
come on the road to its right direction to avoid direct collision i tried to go
28

on my wrong
side to my
right it was in
a split second
i lost my
steering
control and
hit the mile
stone and
then a big
tree.
The Insured
and her
husband
posses valid
driving license.
Insured has not lodge any police complaint from which the loss location
will get confirmed however considering the loss location analysis the
broken parts of the IV were found on the loss.
We asked nearby peoples who resides near the loss location they
confirmed the accident also they confirmed that there were only 2
peoples in the car onel lady and one gents no one was injuried in the
accident.
Accident took place on 13/06/2016,IV reported to workshop on
14/06/2016.
We have procured the pasport and visa of the Insuireds husband to
confirmes the Immigration details please refer below image.

29

30

Conclusion:
Based on our
Field
Investigation and
procured
documents we
are at an opinion
that,
The damages
sustain by the IV
are co relating
with the accident
spot and the
statement of the
Insured who was driving the IV at the time of Accident.No discrepancies has
been evidenced in the said accident.The case seems to be genuine.

31