Affidavit

I, Sunil Kumar S/O V. D. Gupta, aged 44 years, residing at A1, G5, Divinity Homes Apartment,
Indira Nagar Road, Kalyanpur, Kanpur-208026 and permanent resident of B-19 Vikas Nagar East
Hastsal, Uttam Nagar, New Delhi-110059 is the registered owner of motor vehicle bearing registration no.
DL4S BB2070 insured with ICICI Lombard General Insurance Company Ltd under the policy no
3005/226878340/00/000 for a period from Sep12, 2021 to Sep 11, 2022.

I state that the subject vehicle has got stolen Sept 10, 2022, and I have lodged a claim MOT12 with
ICICI Lombard GIC Ltd. However, at the time of loss the insured vehicle was
N.A.___________________________________________________________________ (Reason for
substandard settlement like hire and reward, inordinate delay in registration of vehicle etc. I have
requested the Company to consider my claim on substandard basis.

Name and Signature

(Sunil Kumar)
Place: Uttar Pradesh
Date: 31/10/2022

Verification

I above deponent do hereby verify that the contents of this affidavit are true to the best of my knowledge and
belief.

Signature
 Insured Statement

I, Sunil Kumar S/O V. D. Gupta, aged 44 years, residing at A1, G5, Divinity Homes Apartment, Indira
Nagar Road, Kalyanpur, Kanpur-208026 is the registered owner of motor vehicle bearing registration no.
DL4S BB2070 insured with ICICI Lombard General Insurance Company Ltd under the policy no
3005/226878340/00/000 for a period from Sep12, 2021 to Sep 11, 2022.

I was on my way to temple on dated 10/09/2022 my bike suddenly got stopped backside of CSJM University,
next to Metro Construction Project Site, Lakhanpur, Kalyanpur, Road Connecting to GT Road I parked there and
went to temple and later in search of mechanic but as the time was late so unfortunately, I didn’t found anyone
when I came back to the parked location, my bike DL4S BB 2070 was missing from there and got stolen by the
unknown for which I had filed e-fir 128958/2022 10/09/2022 : 23:42 and FIR no. 0740.

Dated 10/09/2022, Time approx.: 08:00 to 08:45 PM

Location: Backside of CSJM University, next to Metro Construction Project Site, Road Connecting GT
Road. Area-Lakhanpur, PS: Kalyanpur, Kanpur Nagar-208026.

Name and Signature

(Sunil Kumar)
Place: Uttar Pradesh
Date: 31/10/2022