ADP Claim Declaration

Form

Claim Type : Accidental Date : 18/10/2023

Name of the Customer : Mahindra & mahindra Financial Services Limited

Contact/Mobile Number : 7044087774

Service Order / Reference # :

System Serial Number : PF4B47A9

Model / Type : K14

Date & Time of the loss / damage : 17/10/2023 7:15 pm

Place of Incidence : Salt Lake Sector V

Brief description of the loss / damage :

On 17th October 2023, at 7:15pm, i was traveling by toto. The vehicle fell on a
pot hole and toppled over. My laptop got damaged.

Declaration:
I / We agree to provide additional information to the company, if required. I / We, the above mentioned do
hereby, to the best of my / our knowledge and belief warrant the truth of the foregoing statement in every
respect, and if l / We have made, or in any further declaration the company may require in respect of the said
loss / damage. If any of the above is false or fraudulent / any suppression or concealment of details if / when
subsequently discovered, the coverage / protection shall be void for the above mentioned unit and the
company reserves the right to recover the costs in full / part from me / us.

I have / will receive my device repaired / replaced by authorized service center.

Signature of the Customer.