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CONSENT LETTER

WHEREAS, I/We Mr./Mrs./Miss. ASHA P R have obtained an insurance policy/cover note bearing No
2311/59487769/00/002 in respect of my/our Vehicle No KA-41-M-8330 (IV) for the period from 22/02/2019 To
21/02/2020 from Universal Sompo General Insurance Company Ltd.

AND WHEREAS, the said IV was involved in an accident on 24/01/2020 00:00:00 AM and for which a claim
bearing no CL19155743/00001 has been lodged on Universal Sompo General Insurance Company Ltd.

NOW THEREFORE, in consideration of the mutual covenant contained, Universal Sompo General
Insurance Company Ltd. and I/We agree as follows:

First, I/We hereby consent to a full and final settlement of my claim bearing No CL19155743/00001 in respect
of my IV No KA-41-M-8330 under aforesaid Policy Number arising from the subject accident for a sum of
Rs.110000/- (Rupees One lac Ten Thousand Only only) to be paid to me by Universal Sompo General
Insurance Company Ltd.

Second, in response to my/our request to Universal Sompo General Insurance Company Ltd. for
suggesting an alternate mode of settlement in view of me/us not interested in having the vehicle repaired
considering the extent of damage, I/We hereby consent to retain the Salvage (Damaged Vehicle) and deal
with the same in the manner I/We deem fit. I/We fully understand that the full and final settlement as
mentioned herein is arrived after having taken the value of salvage retained by me / us into account.

Third, I/We hereby consent and understand that the said policy/cover note bearing No 2311/59487769/00/002
shall be cancelled by Universal Sompo General Insurance Company Ltd. with effect from the date of
accident mentioned herein.

Fourth, I/We hereby consent that upon final payment of consideration set forth herein, I/We agree to fully
release and discharge Universal Sompo General Insurance Company Ltd. from any and all claims,
demand, and liabilities arising out of or related to the said policy/cover note.

I/We warrant that I/We have read the consent letter, that I/We have had adequate opportunity for review and
consultation, and I/We fully understand the contents hereof.

AGREED & SIGNED

___________________
Signature of Insured
(Rubber stamp in case of Company)

Name of the Insured : ASHA P R

Date: 04/03/2020
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