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__________ on the ____Day of _________ 2007 BETWEEN M/s. ______________
_____________________(herein after called “the insured” which term and
expression shall include his representatives, executors, administrators) is made
in favor of

ICICI Lombard General Insurance Limited, a company incorporated under the
Companies Act, 1956 and having its registered office at ICICI Bank Towers, Bandra
Kurla Complex, Mumbai - 400 051 and corporate office at IInd Floor, Zenith House,
Mahalaxmi, Keshav Rao Khade Marg, Mumbai – 400 034, (hereinafter called “the
Insurer” which term and expression shall include its executors, administrators and

The Insured is the registered owner of a motor vehicle bearing Registration
----------- Bearing engine number -------------------------and chassis number
----------------- (hereinafter referred to as “the said motor vehicle”).

AND WHEREAS the said motor vehicle is insured with the Insurer under the policy of
motor insurance / cover/policy note bearing Number -------------------------- (“the
said Policy) for a period of 12 months from -------------- to ---------------- covering,
inter alia, the risk of loss of or damage to the motor vehicle and / or its
accessories whilst thereon by burglary, housebreaking or theft.

AND WHEREAS the said motor vehicle has been stolen on -------------- and the same
has not been recovered.

NOW IN CONSIDERATION of the payment of the said sum of Rs. ---------------
) By the Insurer to the Insured as cash loss
settlement for the amount of loss and damage suffered by the Insured pertaining
to said motor vehicle resulting from theft and the Insured has accepted the same
as the full, fair and final settlement. THE INSURED HEREBY SOLEMNLY AFFIRMS,

1. By virtue of such payment, the insurer has been subrogated to all the insured’s
rights remedies and in respect of subject matter insured in accordance with the

--------------------. which may arise by the insured and/or any third party against the insurer. -------------------------- (Rupees ----------------------------) to the insurer within a period of thirty 30 days from the date of recovery which shall mean and be computed from the date of delivery to the possession of the recovered said motor vehicle by the competent authority or court either to the insured or to the insured. available to the insurer by virtue of the said policy. shall extend all co. -----------------------. the insurer shall be entitled to recover the said sum of Rs. -------------(Rupees --------------------------) in respect of the said motor vehicle on the faith and strength thereof. The insurer shall be entitled to use the name of the insured for the purpose of recovery of the said motor vehicle including for giving discharge on behalf of the insured for the receipt of the said motor vehicle to the competent authority or court which shall be treated as valid and binding on the insured. The insured further affirms and undertakes that the aforesaid declarations and statement s made by the insured are true and the insurer has agreed to pay the amount of Rs. 2. in full the insurer and keep and hold the insurer harmless in the event of any claim. or in the event that the insured recovers the amount of loss from any third party. and if necessary. Signed and Delivered by ______________________.operation to the insurer for the same. The insured hereby undertakes to indemnify. all of which are expressly reserved by the insurer notwithstanding anything contained herein.(Rupees --------------------------------) with interest at the rate 14% per annum from the date of recovery of the said motor vehicle till the entire amount is realized. The insured agrees and understands that this undertaking shall not stand in derogation of any of the rights. In case of default on the part of the insured. The insured shall at his own instance pursue the recovery proceedings of the said motor vehicle. 4. the insured shall pay the said sum of Rs. the insured shall be liable to repay the said amount of Rs. The within named Claimant in the presence of : 1) 2) . 3. 6. In the event of recovery of the said motor vehicle by any means whatsoever. 5. on account of the said motor vehicle.said policy. or part of parts thereof. In case of non-compliance with the terms herein by the insured and/or if any hindrance is caused of the part of the insured.(Rupees ----------------------------) to the insurer on demand together with interest @ 14% per annum from the date of payment by the insurer as aforesaid.