UNDERTAKING

To,
M/s. Bajaj Allianz General Insurance Company Ltd.,

Reference Claim no: Policy No :

Name of Insured : Vehicle Regd No.
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. ______, bearing chassis No. ______ was
owned by me and insured with your Company vide above policy for the period
from _______ to ______ for a sum insured of Rs. ________/-.
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. _______ 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 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 Date: Place:

Signature of the witness Date Place

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