CONSENT LETTER-CASH LOSS

I, NIRAJ KUMAR have obtained a comprehensive insurance Package policy from Bajaj
Allianz General Insurance Co Ltd, Office address -3rd Floor, Naraian Building, Shahnajaf
Rd ,Hazaratganj,Lucknow,Uttar Pradesh 226001, UP vide policy No OG-23-9906-1801-
00111429 in respect of my vehicle No HR29AD1068, Engine No K10BN1591115, and
Chassis No.MA3EPDE1S00545928 and the period from 15-JAN-2023 to 14-JAN-2024.
During the existence of the said policy the said vehicle met with an accident and sustained loss
on 13-NOV-2023.
After the mutual discussion and negotiation, I have voluntarily accepted full & final settlement of
my claim hereunder and declare that:

1. I hereby agree to accept the sum of Rs. 134366 /- (One Lakh Thirty Four Thousand
Three Hundred Sixty Six Only) as mutually negotiated full and final settlement excluding
the value of damaged vehicle, which will be retained by me.
2. I hereby undertake that I have retained the damaged vehicle and taken possession of
the same.
3. I hereby undertake that I will sell the above referred vehicle of my own choice and for
that I undertake not to make any claim on Bajaj Allianz General Insurance Co Ltd.
4. I hereby accept that Bajaj Allianz General Insurance Company is not liable with regard to
this claim or the vehicle what so ever and I undertake not to raise any issue or dispute
regarding the same or make any claim on this on Bajaj Allianz.
5. I hereby authorize and consent Bajaj Allianz to cancel my policy from the date of
accident.
6. I hereby undertake to cancel the registration certificate from the date of accident.
7. I hereby absolve Bajaj Allianz of all future responsibilities and liabilities with regard to the
sale of the aforesaid vehicle or any further legal litigation.
8. I hereby undertake to execute sale deed with the buyer and submit the copy to RTO for
information regarding the sale in the event of sale of the vehicle to any other person.
9. I undertake that I will never raise an issue, or litigation on this mode of mutually
negotiated settlement.
10. This consent letter has been voluntarily given and I am aware that the same is a
condition precedent for the mutually agreed mode of settlement.
Date:
Name & Signature of
Insured
Name & Signature of Witness