MBD Survey Report Format

- Surveyor name - address - Communication Communication address Surveyor Ref:

/ MBD /

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.)

   Y    C    I    L    O    P    E    C    N    A    R    U    S    N    I    S    R    A    L    U    C    I    T    R    A    P

   N    W    O    D    K    A    E    R    B    S    L    I    A    T    E    D

   S    R    A    L    U    C    I    T    R    A    P    Y    E    V    R    U    S

 

Name of the insurer

Name of the insured

:

:

Policy number

:

Period of insurance

:

Type of policy

:

Premises / works address

:

Item insured as per policy

:

Total sum insured

:

Total premium charged

:

Fai Failed it item cove overed red in in pol poliicy

:

Sum Sum insu insure red d for for fai faile led d mac machi hine ne

:

Initial policy excess

:

Date of break down

:

Time of break down

:

Witness of the occurrence

:

Place of occurrence

:

Repair work attended by

:

Amou Amount nt clai claime med d by by the the insu insure red d

:

Survey work appointed by

:

Date of appointment

:

Date of survey

:

Place of survey

:

Person present during survey

:

Purchase invoice particulars

:

Details of guarantee period

:

Function of the machine

:

Machinery break down

Sche Schedu dulle ser seriial num number :

- Surveyor name - address - Communication address    T    I    N    U    D    E    L    I    A    F    F    O    S    L    I    A    T    E    D    E    L    B    A    R    U    S    N    I    T    S    E    R    T    N    I    F    O    Y    C    A    U    Q    E    D    A    D    E    R    U    S    N    I    M    U    S    E    H    T    T    U    O    B    A    K    S    I    R

Details of log book  

:

Name plate details

Details of damage

: :

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.

Insured value of the machine failed machine

:

Rs.

Present cost of the new machine

:

Rs.

  New machine quotation received from

Remarks

:

M/s.

:

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.

   E    S    U    A    C    S    S    O    L    F    O    /    E    F    I    L    T    U    O    B    A

- Surveyor name - address - Communication address    N    O    O    I    A    I    C    E    R    P    E    D    E    G    A    V    L    A    S    T    U    O    B    A    T The sudden, unforeseen physical loss / damage to the insured property had    N    E    M of insurance and due to a peril not excluded in the policy.    S    S There is no breach of warranty nor willful act / negligence on the part    E    S    S opinion the claim is admissible.    A    S    S  I have given below my assessment.    O    L

SL No

   S    T    N    E    M    M    O    C    R    O    Y    E    V    R    U    S

Particulars

Qty

occurred during the period of insured. Hence, in my

Estimate

Assessed

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. I have disallowed the Labour charges for replacement of parts since the machine was under AMC with M/s. The claim is admissible. 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 XX.XX.XXXX . Copy of invoice and payment details were collected and enclosed for your reference.

   E    R    U    T    A    N    G    I    S

Surveyor.    S    E    R    U    S    O    L    C    N    E

Survey bill

Photos taken by me

XX

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.