UNDERTAKING

To,
 M/s.Bajaj Allianz General Insurance Company Ltd.,
Reference Claim nO:-21-D3-11D0D47D Policy No0G2901-1ODDS7704
Name of Insured:St                         Vehicle Regd No.f-D D 647S
Date of Accident:-9-0               Time of Accident:P
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 NoPIK6bearing chassis No.HC39
 was owned by me and insured with your Company vide above policy for the period from
to232ofor a sum insured of Rs000
 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.oras 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. 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 not raise any legal issue with regards to the settlement agreed upon.
           Signature of the Insured

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