UNDERTAKING

To,
M/s.Bajaj Allianz General Insurance Company Ltd
                                                                  PalicyNoO20-=18D-0006491

Date of Accident:     Time of Accident:ASoPm
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:

was owned by me and insured with your Company vide above policy for the period from
/11 to7/102for a sum insured of Rs.31623
That the said vehicle met with an accident on date and time mentioned above. Based on
my request the quantum of loss to the vehicle has been evaluated by the designated
surveyor for Rs.5eas 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 oondition 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. I 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 npt raise any legal issue with regards to the settlement agreed upon.
           Signature of the Insured                  Date:            Placem EERJT
                                                              16/102020

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