Date: 07/03/2019

To,
HDFC Ergo General Insurance Co. Ltd.
6th Floor, Leela Business Park,
Andheri-Kurla Road,
Andheri [East]
Mumbai- 400 059.

Sir,

Ref: My Vehicle Maruti Suzuki Swift VDI_bearing Regd. No. UP32 JB 5690, Policy
No. 2311201851140501000 & Claim No. C230018341797

I the undersigned owner of Maruti Suzuki Swift VDI bearing registration number UP32 JB 5690
do hereby agree to and accept treatment of the claim on “CASH LOSS / NET OF SALVAGE /
TOTAL LOSS” basis for consideration of Rs. 5, 78, 000/- (Rupees Five Lakh Seventy Eight
Thousand Only) less salvage value as obtained by yourselves in full and final settlement of own
damage claim loss occurred on 29/12/2018 . I authorize the Insurers to facilitate me in obtaining
the best salvage value through the resources available and the salvage shall be handed over to the
salvage buyer. It is hereby understood that this aforesaid transaction between myself and the
salvage buyer is being facilitated by yourself without any charges.

I hereby agree to surrender insurance certificate and policy for necessary cancellation without
consideration of any refund of premium for the unexpired period. I accept to hand over possession
of the salvage with clear title including all original transfer documents and will clear all
outstanding dues of the workshop including but not limited to estimation/garaging charges, etc. I
undertake and agree to clear all outstanding loans including any top up loans where the subject
vehicle has been held as security prior to settlement of this claim.

I hereby agree to accept that I will permit the salvage buyer a period of 120 days from its lifting
date to enable the vehicle repairs and further transfer and I will not claim for any further
encumbrances incurred due to this process.

It is understood that above settlement is subject to the terms and condition and provisions of the
policy in force at the time of mishap and also subject to your accepting liability there to.

* Signature of the Insured

Name of Insured: JAYESH BAJPAI
Address: E – 4052 – 54, Sector – 11,
Rajajipuram, Lucknow – 226017

Company Confidential