DATE: -

TO WHOMSOEVER IT MAY CONCERN

Sub. Claim No. --------------------------------------------------- Under policy for claim Amount with
reference to the above, I am Mr./Mrs.--------------------------------------------------------

Do not have any objection towards the releasing claim amount directly to GK energy marketers Pvt..
Ltd. From M/S IFFCO-TOKIO GENERAL INSURANCE COMPANY LTD.

Farmer Name & Signature with Phone Number

Farmer Name: - ………………………………………………

Mobile Number: - ……………………………………………

Customer ID: - …………………………………………………