UNDERTAKING
        To
        M/s.Bajaj Allianz General Insurance Company Ltd.
         Reference Claim no:oc-21-13o2-1226-vobo                                                                                         Policy No:
        Name of InsuredRa=                                                                                         3262
                                                                                                                                          Vehicle Regd No.UPFL123s
          Date of Accident:                                                                                                               Time of Accident:
         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.uFu123bearing chassis No.                                                                                                                                                                             S
          owned by me and insured with your Company vide above policy for the period from
        1uto zu2for a sum insured of Rs.y7/
            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 Rs2/- 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-
                               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.
                              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.
                               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.
                               I will not make any profit out of the claim settled in any form what so ever.
                                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.
                                I will not raise any legal issue with regards to the settlement agreed upon.
                                    71
                                                                                                                                        Date:                                 Place:
                                 Signature of the Insured
                                                                                                                                         Date                                 Place
--------------PAGE END-----------------------