AFFIDAVIT

FROM
MRS.SHANTHI V
NO.17/31 – B, SARATHAMBAL NAGAR
KARUMATHAMPATTI,
SULUR TALUK,
COIMBATORE – 641659.
TO
M/S.NEW INDIA ASSUTANCE COMPANY LIMITED,
CLAIMS HUB,
COIMBATORE.
REF :
CLAIM UNDER POLICY NO : 11300031180300794859
PERIOD OF INSURANCE : 26/04/2018 – 25/04/2019
ACCIDENT VEHICLE NO : TN-37-CV-6201
MODEL : HYUNDAI I20 SPORTS VTVT – 2016
 This is to certify that I have lodged the captioned claim in respect of damages to
my insured vehicle in an accident on 30/04/2018 at about 5.00 PM.
I hereby confirm the truth and veracity of the occurrence of the accident and the
damages to the vehicle as indicated by me in the claim form.
1. The accident took place on 30/04/2018 at about 5.00 PM, while the driver Mr.
Ramasamy was proceeding on my Hyundai i20 Sports VTVT car bearing Reg
No. TN-37-CV-6201, nearby sulur, coimbatore highway, Lorry which was going
front, applied break and stopped, as a result, my driver dashed the car at the
back of the lorry and thereby caused damages to my vehicle in the front portion.
2. In the said accident, no damage or injury caused to any third person.
3. The Driver Mr.Ramasamy having Valid driving license.
4. If any other third party injuries claim arises in future by this accident, I will hold
the entire responsibility.
5. I also not registered any complaint with concerned police since third party
property or life is not involved.
6. I depose this affidavit for insurance claim purpose.
7. I future state that in such circumstances, I admit and agree that insurer has
accepted my representation about the bonafides of the accident and claim and
settled the same even in the absence of the F.I.R believing my representation
8. Hence, I admit and agree that in case it turns out the facts as represented by me
to support my claim is shown to be no true, then I agree to refund the sum settled
to the insurer under the contract of insurance without any let or hindrance.

Solemnly affirmed and signed before me

On 07/05/2018 at Coimbatore.