AFFIDAVIT

My self-Rakesh Kumar S/o Shri. Om Prakash, resident of V.P.O Rupana, Tehsil & District Sri Muktsar
Sahib. I hereby declare that:

1) I, own a Swift Dzire – ZDI car, having registered driving licence issued by Punjab State
(Licence no.: PB – 3020080067791) which is valid till 23 rd December 2027, bearing
registration number PB 30 S 7002, chassis number: MA3FJEB1S00933978, engine number:
D13A2824926, model – 2016. This car insurance is with Universal Sompo General Insurance
company limited.
2) On 20th December 2021 I was going from Muktsar to Rupana around 8:30 am, when I
reached Gardenia Palace my car was hit by a pickup from behind due to which my car has
got imbalanced and the car was flown away in to the fields and the left side of the car has
got hit with the tree and became upside down.
3) There was no fatality in this accident, I have not filed any case with the police regarding this
accident.
4) There was no damage caused to the third party in this accident.
5) Now I want to claim the damage caused due to this accident.

Signature of Affiant

Declaration

I solemnly state that the contents of this affidavit are true to the best of my knowledge and
belief and that it conceals nothing and that no part of it is false.

Signature of Affiant
Date: