Dated:

To,

Manager
ICICI Lombard GIC Ltd
(Branch address)

Dear Sir/Madam

Subject: Declaration of Mismatch of name

Reference: Policy no. _________________________

With reference to the captioned subject, this is to inform you that

__________________________ (Name of the insured/Company) hereby declares that our name
reflecting on the __________________(Name of the document) provided herewith belongs to us.
Our name as per the policy is______________________________ (Name as per policy copy)
and our name as per the cheque leaf is __________________________ (Name as per document).

The reason for the difference/mismatch of name as per the policy and as per the document is
_________________________________(state the reason), hence based on this declaration,
request you to consider the same and process the policy for cancellation and refund.

Name of the insured Company

Signature of Authorised Signatory