CASH LOSS CONSENT

To Date: _____________
The Manager
Bajaj Allianz General Insurance Co.
City.

CONSENT LETTER-CASH LOSS EXLUDING DAMAGED VEHICLE

I, DIMPAL TYAGI have obtained a comprehensive insurance Package policy from Bajaj Allianz General Insurance Co
Ltd, Office address Delhi vide policy No OG-21-1120-1871-00000219 in respect of my vehicle UP15CU6566, Engine
No U7350338, and Chassis No. JU350914 and the period from 12-MAR-2021 to 11-MAR-2022. During the existence
of the said policy, the above referred vehicle met with an accident and sustained loss on date 11-SEP-2021 .

After the mutual discussion and negotiation I have voluntarily accepted full & final settlement of my claim hereunder
and declare that:
1. I hereby agree to accept the sum of Rs SIXTEEN THOUSAND SEVEN HUNDRED TWENTY EIGHT ONLY(
Rs 16728/-)mutually negotiated full and final settlement excluding the value of damaged vehicle , which will
be retained by me.
2. I hereby undertake that I have retained the damaged vehicle and taken possession of the same .
3. I hereby undertake that I will sell or repair the above referred vehicle and for that I undertake not to make
any claim on Bajaj Allianz Generel Insurance Co .
4. I hereby accept that Bajaj Allianz General Insurance Company is not liable with regard to this claim or the
vehicle what so ever and I undertake not to raise any issue or dispute regarding the same or make any
claim on this on Bajaj Allianz.
5. I hereby authorize and consent Bajaj Allianz to cancel my policy from the date of accident.
6. I hereby absolve Bajaj Allianz of all future responsibilities and liabilities with regard to the sale or repair of
above vehicle or any further legal litigation.
7. I hereby undertake to execute sale deed with the buyer and submit the copy to RTO for information
regarding the sale in the event of sale of the vehicle to any other person.
8. I undertake that I will never raise an issue, or litigation on this mode of mutually negotiated settlement.
9. This consent letter has been voluntarily given and I am aware that the same is a condition precedent for the
mutually agreed mode of settlement.

Date:
Name & Signature of Insured
Name & Signature of Witness
Annexure-1