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INSURANCE REGULATORY AND DEVELOPMENT AUTHORITY - page 27 / 28

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Regulation No. 12(l)

S.No.

Name and address of the Insured

Name & Address of the Insurer

Policy No.

Dept in which the claim falls

Dt of allocation of survey work

Dt of survey/ inspection

Dt of submission of survey report

Amount of Claim assessed

Survey Fee Details (Amnt/ dt. of payment)

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