SUBROGATION CUM UNDERTAKING

To

Broker Cell,MRO,III,Mumbai.

Received from The Oriental Insurance Co. Ltd., (hereinafter called "THE COMPANY") a sum of
Rs. (Rupees only) in full and final
settlement satisfaction and discharge of all my/our claims on account of payment under Claim
No:_____________ due to me in respect of loss of / to my No On or
about Insured with the Co. my/our Insured with the
Company under Policy No in consideration of the aforesaid
payment of Rs. which is hereby acknowledged, I/We, give the undertaking
as under:

That I/we do have no claim whatsoever against the Company and/or their Agents and/or servants in
respect of concerning or arising out of the aforesaid and all my/our claims past, present and future
in respect of the said do stand full and finally settled,satisfied and
discharged.

That by virtue of the payment received by me / us, I/We hereby subrogate and abandon to the
Company all our rights and remedies and title and interest in and in respect of any property into
which the money fully or in part is converted and the proceeds of the said property and all that can
or may in anyway be made, saved and realised either in cash or in the shapes of property if
converted as the case may be. I/We hereby grant the Company full power to take all lawful actions
in my/our name or in your name otherwise to save and realise the money or property or its proceeds
and I/We hereby subrogate to the Company the same rights and remedies as I/We have in
consequence of or arising from the said loss.

I/We hereby undertake and agree to recover any property or proceeds of such property from the
Policy or any other Authorities which stand due on Completion of the legal proceedisng and hereby
agree to deposit the said property or cash with the Company.

I/We hereby further undertake and agree to make and execute all further deeds, assignment and
documents at Company's cost and render such assistance as Company may reasonably require for
the purpose.

I/We further hereby undertake and agree that any further recoveries made from Police or any other
source by me/us will be made good to the Company. That I/We further hereby agree and undertake
that in case of the loss being proved by any Competent Authority as non-admissible in terms and
conditions of this Company in full settlement wil be returned to the Company forthwith on demand

IN WITNESS WHEREOF I/WE have set our respective hands on this ______ day of
_____________2014.