From

______________________
Address
____________________________
____________________________
____________________________

To
The Branch Manager,
Shriram Transport Finance Company Ltd.,
_________________________________

Sir,
I consent for the following
Name of the Plan
Name of the Proposer

:
:

Vehicle Number

Cover Amount

I hereby declare that the feature/benefits of group life protector policy offered by Shriram Life
Insurance Company are explained to me in detail and I wish to apply for this policy cover. I also
understand and accept that the amount payable in case of claim will be as per the benefit/
amortization schedule arrived at _____ monthly reducing. In case of any claim, the claim amount
may be paid to the master policy holder to adjust towards my vehicle loan outstanding. Please
deduct Rs.__________ from loan amount and pay this towards premium for the said policy and issue
me the cover. I declare that I am in good health.

Date:

Yours Sincerely,