UNDERTAKING
  To,
  M/s.Bajaj Allianz General Insurance Company Ltd.
                                                         PolicyNo:002|-20-1B02-0000U10l
                                                        Vehicle Rega No.UP 19 3925
                                                         Time of Accident
                                                                              1955:00
 I above named insured do hereby state, declare and undertake as follows and firmly
 bound my self unto you (The Bajaj Allianz General Insurance Company Ltd.), and state
 to indemnify you in the whole sum amount in consideration of you having paid the said
 amount to me in the following circumstances:
 That the vehicle bearing Regd No.Up 19 92$bearing chassis No. S9ByS
 was owned by me and insured with your Company vide above policy for the period from
tofor a sum insuredof Rs.
 That the said vehicle met with an accident on date and time mentioned above. Based on
 my request the quantum pf loss to the vehicle has been evaluated by the designated
 surveyor for Rs.5as full and final as per the terms and condition of the policy
 and the same is agreeable to me.
 Further I do hereby undertake that:-
      1. I will fully utilize the claim amount paid in advance by you to get the vehicle
          repaired within 7 days from the date of payment and bring back the vehicle to the
          shape and condition prevailing before the accident.
     2.I will produce the vehicle after repair along with the bills and other documents to
         prove that vehicle have been repaired and restored to the original shape and
         condition prevailing prior to the accident.
     3.l will not make any claim again for the damages already claimed against above
         claim in any form what so ever in the remaining period of the policy.
     4.I will not make any profit out of the claim settled in any form what so ever.
     5.I here by authorize M/S Bajaj Allianz to cancel the policy, adjust the premium
         against claim expanses and recover the amount paid against the above mention
         claim in case of violation of the undertaking as mention hereinabove.
     6. I will not raise any legal issue with regards to the settlement agreed upon.
                                                     409200
         Signature of the Insured               Date:           Place:SHAMLI

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