(STAMP DUTY AS APPLICABLE IN STATE)

IDEMNITY CUM DECLARATION UNDERTAKING

THIS IDEMNITY CUM DECLARATION UNDERTAKING (“Undertaking”) made at __________on the

____Day of _________2015 BETWEEN M/s. ______________ (herein after called
“the insured” which term and expression shall include his representatives, executors, administrators) is made

in favour of

ICICI Lombard General Insurance Limited , a company incorporated under the Companies Act, 1956 and having
its registered office at ICICI Bank Towers, Bandra Kurla Complex, Mumbai - 400 051 and corporate office at
IInd Floor, Zenith House, Mahalaxmi, Keshav Rao Khade Marg, Mumbai – 400 034, (hereinafter called “the
Insurer” which term and expression shall include its executors, administrators and assigns).

WHEREAS

The Insured is the registered owner of a motor vehicle bearing Registration Number
------------------------------ Bearing engine number -------------------------and chassis number -----------------
(hereinafter referred to as “the said motor vehicle”).

AND WHEREAS the said motor vehicle is insured with the Insurer under the policy of motor insurance /
cover/policy note bearing Number -------------------------- (“the said Policy) for a period of 12 months from
-------------- to ---------------- covering, inter alia, the risk of loss of or damage to the motor vehicle and / or its
accessories whilst thereon by burglary, housebreaking or theft.

AND WHEREAS the said motor vehicle has been stolen on -------------- and the same has not been recovered.

NOW IN CONSIDERATION of the payment of the said sum of Rs. --------------- (Rupees
) by the Insurer to the Insured as cash loss settlement/ total theft for the amount of
loss and damage suffered by the Insured pertaining to said motor vehicle resulting from theft and the Insured has
accepted the same as the full ,fair and final settlement,
THE INSURED HEREBY SOLEMNLY AFFIRMS, DECLARS, UNDETAKES AND STATES AS
FOLLOWS:

1. By virtue of such payment, the insurer has been subrogated to all the insured’s rights remedies and
in respect of subject matter insured in accordance with the said policy. In the event of recovery of the
said motor vehicle by any means whatsoever, or in the event that the insured recovers the amount of
loss from any third party, the insured shall pay the said sum of Rs. -------------------------- (Rupees
----------------------------) to the insurer within a period of thirty 30 days from the date of recovery which
shall mean and be computed from the date of delivery to the possession of the recovered said motor
vehicle by the competent authority or court either to the insured or to the insured. In case of default on
the part of the insured, the insurer shall be entitled to recover the said sum of Rs. ---------------------
(Rupees --------------------------------) with interest at the rate 14% per annum from the date of recovery
of the said motor vehicle till the entire amount is realised.

2. The insured shall at his own instance pursue the recovery proceedings of the said motor vehicle, and
if necessary, shall extend all co- operation to the insurer for the same. The insurer shall be entitled to
use the name of the insured for the purpose of recovery of the said motor vehicle including for giving
discharge on behalf of the insured for the receipt of the said motor vehicle to the competent authority or
court which shall be treated as valid and binding on the insured.

3. In case of non-compliance with the terms herein by the insured and/or if any hindrance is caused of the part of
the insured, the insured shall be liable to repay the said amount of Rs. ------------------------ (Rupees
----------------------------) to the insurer on demand together with interest @ 14% per annum from the date of
payment by the insurer as aforesaid.

4. The insured hereby undertakes to indemnify, in full the insurer and keep and hold the insurer harmless in the
event of any claim, which may arise by the insured and/or any third party against the insurer, on account of the
said motor vehicle.

5. The insured further affirms and undertakes that the aforesaid declarations and statement s made by the insured
are true and the insurer has agreed to pay the amount of Rs. -------------(Rupees --------------------------) in
respect of the said motor vehicle on the faith and strength thereof.

6. The insured agrees and understands that this undertaking shall not stand in derogation of any of the rights, or
part of parts thereof, available to the insurer by virtue of the said policy, all of which are expressly reserved by
the insurer notwithstanding anything contained herein.

Signed and Delivered by ______________________,

the within named Claimant in the presence of :

1)

2)