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                                                         AFFIDAVIT/UNDERTAKING IN CASE OF CASH/SPOT SETTLEMENT
                               To,
                                M/s Bajaj Allianz General Insurance Company Ltd.,
                                Reference Claim No. OC-22-1205-1825-00000561
                                Policy No. OG-21-1229-1825-00000229
                                Name of Insured:ATHARA JI
                                Vehicle Registration No. JK01AN1736
                                Date of Accident:16-AUG-2021
                                Time of Accident: 02:15 PM
                              118
                                           cf
                 SCRON'TIGS                 above named insured do hereby state, declare and undertake as follows and
          C      sin
                                having paid the said amount to me in the following circumstances.
       uol                      That the vehicle bearing Registration No. JK01AN1736 bearing chassis no
                                MA3EUA61S00G77780 Engine no. 6425425 was owned by me and insured with
                               your company vide above policy for the period from 27-NOV-2020 to 26-NOV-
                                2023 for a sum insured of Rs.346000/
                                That the said vehicle met with an accident on date & time mentioned above.
                                Based on my request the quantum of loss to the vehicle has been evaluated by
                                the designated surveyor for Rs. 75203/-less policy excess Rs.2000/- = Net
                                Rs.73203/- (Rs. Seventy three Thousand two hundred three only) as 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 theoriginal 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.
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                                 5. I hereby authorize M/S Bajaj Allianz General Insurance co. Ltd 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 herein above.
                                6. I will not raise any legal issue with regards to the settlementagreed upon
                                                                                                        ATHARA.
                                Signature of the Insured:
                                Date:14/03/2022                                             Place: Srinagar
                                Signature of the Witness
                                Date:14/03/2022                                              Place: Srinagar                                      Certifiedthat the Stalementdeciareu
                                                                                                                                                  pn oath bymg.ai Sringgston the
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