TO PRINT ON RS.

100/- STAMP PAPER

Date:

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

Sir,

Ref: My Vehicle ___________________ bearing Regd. No.______________, Policy No.

______________________& Claim No.____________________

I the undersigned owner of (vehicle make)___________________________bearing registration number

__________________ do hereby agree to and accept treatment of the claim on “CONSTRUCTIVE TOTAL
LOSS” basis for consideration of Rs._______________ (Rupees _________________________________
__________________________________ only) in full and final settlement of own damage claim for the
loss which occurred on / /20 .
I authorize the Insurers/Surveyors to facilitate me to identify the best salvage value through the resources
available. The salvage shall be either retained by me or handed over to the salvage buyer at my own
behest. It is hereby understood that this aforesaid transaction between myself and the salvage buyer is only
being facilitated by yourself to identify its value 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. In event of hand over of the salvage to the identified
buyer, I accept to release 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, parking
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 understand and agree that the complete transaction including vehicle ownership transfer shall be
concluded by myself.

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

Sign *

Name of Insured:
Address:

Witness______

* Signature of the Insured