(This is required on stamp paper of Rs. 100/-.

The document must be notarized on

all pages.)

AFFIDAVIT/CONSENT

Affidavit regarding legal heirs of Late ___________________ (Name of the Deceased)

S/O _____________________ (Father’s Name), to be produced to The Bajaj Allianz
General Insurance Company Ltd., by (1) ___________________________ (2)
________________________________ and (3) _____________________________,
((Name with relationship with the deceased, Age and Occupation of the legal heirs) being
the claimants of the PA claim amount.

WE,
Name with relationship with the deceased , Age and Occupation of the legal heirs
1.
2.
3.
All residing at: ________________________________________ (Full address), do hereby
solemnly affirm and declare as under:

1. That the following persons are the only legal heirs of the Late
___________________________ (Name of the Deceased), who was permanently
residing at ___________________, and who expired on __________________ in
accident dated _________________.

The names of the legal heirs of the above deceased

________________________________________________________________________
Sr. Name Age Relationship with deceased
-------------------------------------------------------------------------------------------------------------------
1
2
3
 2. We understand that relying on this affidavit the Bajaj Allianz General Insurance
Company Ltd., has agreed to process the PA claim application made by us in respect
of the accidental death of Late ______________________.

3. We do hereby state and declare that we are the only legal heirs of Late
________________________ (Name of the deceased) S/o.
______________________ (Father’s Name) entitled to receive the PA claim
amount. We have no objection to hand over the said amount of Rs.
________________/- to one of us _____________________ (Name of the
Nominee).

Solemnly affirmed at Pune on this ______________ day of ___________ Year_______.

I know the Affiants

1. Name: 2. Name: 3. Name:
Signature: Signature: Signature: