THE ORIENTAL INSURANCE CO.LTD.

,
DO- I COIMBATORE.
AVIATION CLAIM NOTE

Dept: AVIATION 27.03.2019

Ref : CLAIM NO : 451100/43/2017/000001

POLICY NO :451100/43/2017/2

SUMMARY PARTICULARS:

1)Name of the Insured/Claimant :M/S LAKSHMI MACHINE WORKS LTD

2) Policy ssuing Office :DO I COIMBATORE-451100

3) Insurance Particulars :

Sl.No Policy No. P.O.I Description Sum Insured Premium

of Risk (Rs.) (Rs)
1 451100/43/2017/2 20.09.2016 AIRCRAFT 25 CRORES 562228
TO
19.09.2017

4 )Details of Endt : NIL

5) Risk Covered : AIRCRAFT MODEL BEECHCRAFT

KING AIR B-200

AIRCRAFT DETAILS:

YEAR OF REGD, NO. DECLARED AIRCRAFT

MIN AIRCRAFT SEATING VALUE
MODEL CAPACITY
948874428 BEECHCRAFT 2017,REGN.NO.VT-LMW 7 RS.25 CRORES
KING AIR B-200 S.NO.BB-1998-ID MARK TDB
BEECHCRAFT KING
AIRB200 WITH MODEL
NO.PT6A-42 PRAT &
WHITNEY CANADA ENGINE
S/N PCE PJ10941, PCE
PJ1093

6) a) Co-insurance details, if any : NIL

b) When “On a/c” Payment Made

Give status of recoveries from
 Co-insurers : NOT APPLICABLE

7) a) Re insurance details(By H.O.)

b) When “On A/C payment made
give status of recoveries from
insurers : NOT APPLICABLE

PILOT DETAILS:

S.NO PILOT NAME PILOT DETAILS DATE OF VALIDITY ENDORSEMEN

BIRTH D.O.MED. T
ON AIRCRAFT

1 SUBIR ROY PILOT 15.09.1963 12/08/17 20.10.2008

2 VINIT MOHITE CO-PILOT 14.09.1981 23.03.2017 29.11.2010

8)CERTIFICATE OF REGISTRATION : 08.10.2007 (N.DELHI)

9)Date of Loss : 15.02.2017

10)Cause of loss : BIRD STRIKE DAMAGE TO

BEECHCRAFT WHILE LANDING AT
BANGALORE HAL AIRPORT

11)Place of Loss : AT BANGALORE HAL AIRPORT

12) Affected Items covered under the

Policy /Repairer : Yes / M/s.Indamer Aviation Pvt.Ltd.,
Mumbai

13) Estimated amount of Loss -RS.19,81,973/-

14) a) Name of Surveyors

Preliminary : NIL
- Final : WG. CDR.B.B.KHANNA
b) Name of Investigator : NIL

15) Survey Report No & Date : BBK/AVN/BIRD-STRIKE/VT-

LMW/BEECH-CRAFT/KING
AIR/BANGALORE DATED 22.03.2019

16) a) Compliance of Sec.64VB of Ins.Act

1938(Details as per format) : Yes –
 -Payment by Cash/Cheque/CD : CD NO.AA0000024212

17. Surveyor’s recommendations/observations as to liability:

The bird hit damages are accidental and are payable under the policy terms
and conditions. Insured has complied with all requirements, including
insurers and DGCA. Aircraft was serviceable during this flight, AME and
pilots had valid licenses and DGCA was informed of the bird hit damages and
repairs were carried out as per manifacturers and DCGA guidelines and
Insured followed correct procedures and the Insureds claim of Rs.18,81,418/-
is recommended for payment.

DOCUMENTS SUBMITTED-

1. CLAIM INTIMATION
2. POLICY COPY
3. 64 VB COMPLIANCE FORM
4. CLAIM FORM
5. ESTIMATES
6. AIRCRAFT DETAILS
7. WILDLIFE (BIRD/ANIMAL) STRIKE FORM-REPORTED BY PILOT
8. TECHNICAL LOG
9. PERMISSION FOR REPAIRS
10. REPAIR INSTRUCTIONS
11. REPAIRERS A.M.E
12. A.M.E.LICENSE
13. PILOT LICENSE
14. CO-PILOT LICENSE
15. INDIA METEOROLOGICAL DEPARTMENT FLIGHT FOLDER (WEATHER)
16. CERTIFICATE OF REGISTRATION
17. CERTIFICATE OF AIRWORTHINESS
18. AIRWORTHINESS REVIEW CERTIFICATE
19. RENEWAL CERTIFICATE
20. SPECIAL FLIGHT PERMIT TO FERRY DATED 21/02/2017
21. AIRCRAFT CERTIFICATE TO RELEASE TO SERVICE
22. FLIGHT PLAN
23. POST FLIGHT PILOT REPORT
24. PHOTOGRAPHS
25. VARIOUS BILLS/INVOICES
26. INDAMAR INVOICE NO.1501/A17/REM/2/17-18 DATED 18.04.2017
27. INDAMAR INVOICE NO.1501/A17/REM/1/17-18 DATED 18.04.2017
28. AIR TICKET COIMBATORE TO MUMBAI DATED 23/02/2017
29. INDAMAR ENG & MAINTENANCE WORK ORDER FORM
30. INDAMAR PO/LMW/16-17444 DATED 01/03/2017
31. INDAMAR INVOICE NO.1501/A02/INS/1/17-18 DATED 08/04/2017
32. AIRTICKET MUMBAI TO BANGALORE DATED 21/02/2017
33. AIR TICKET BANGALORE TO MUMBAI DATED 21/02/2017
34. INDAMAR INVOICE NO.1501/A17/INV/329/16-17 DATED 31/03/2017
35. INDAMAR INVOICE NO.1501/A17/330/16-17 DATED 31/03/2017
36. INDAMAR INVOICE NO.1501/A17/INV/1/17-18 DATED 08/04/2017
37. INDAMAR INVOICE NO.1501/A17/INV/329/16-17 DATED 31/03/2017

ASSESSMENT OF LOSS:
18.“ON A/C PAYMENT” if any already made : NIL

19. “ON A/C BALANCE PAYMENT” to be made : NIL

20 Amount if any to be retained pending clarifications/

Certifications from the Insured/Surveyors : NIL

23)Claim Department’s observations as to liability :

We received a mail from the insured on 15.02.2017 informing us that

Beechcraft had hitted by bird while landing at Bangalore Airport. HO had
deputed WG.CDR.B.B.Khanna for Survey and assess the loss. The Surveyor
submitted his report on 26/03/2019, recommended that the bird hit damages
are accidental and are payable under the policy terms and conditions. Insured
had complied with all requirements. Aircraft was serviceable during this
flight, AME and pilots had valid licenses and DGCA was informed of the bird
hit damages and reqpairs were carried out as per manufactuters and DCGA
guidelines and Insured followed correct procedures .

As recommended by the Surveyor WG.CDR.B.B.Khanna, claim is

recommended for settlement of Rs.18,81,418/- (Eighteen Lakh eighty One
Thousand Four Hundred Eighteen) to the Insured.

Submitted for approval.