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Date:

To,

Tata-AIG General Insurance Co. Ltd.

H. No 7-1-6-617/A, GHMC no - 615,616,

5th (Part) & 6th Floor, Imperial Towers,

Ameerpet, Hyderabad – 500016

Sub.: Satisfaction Letter/ Discharge Voucher

Claim Number-__________________________Policy Number-_____________________________

Vehicle Number__________________________A/c.-_____________________________________

Dear Sir/ Madam:

After inspecting my vehicle repaired by M/s.______________________________________________

I/we hereby confirm that the damages claimed by me/us under the above mentioned claim have been

repaired to my/our utmost satisfaction. I/we request you to kindly pay the claim amount of

Rs.____________(Rupees_______________________________________________________) directly

to them. I/we have paid the amount of Rs.____________(Rupees______________________________)

towards depreciation and/or extra work done on my/our vehicle.

I/we accept the settlement in full and final and discharge of all liabilities arising out of this claim upon

Tata-AIG General Insurance Co. Ltd.

Regards,

Signature of Insured Name__________________________

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Rubber Stamp in case insured is a firm