AFFIDAVIT
I, Gummalla Saurav Shekar, S/o. Gummalla Madhu Shekar Resident
of H.No. 19-1-953, Puranapool, Bahadurpura, Hyderabad-500064, T.S. do
hereby state on solemn affirmation as under –
1. That, I am the registered owner of Maruti Suzuki Ertiga ZXI 2023
bearing Registration Number TS 12 EX 0404 Engine Number
K15CN9145122 and Chassis Number as MA3BN62SNM563163 (hereinafter
for the sake of brevity be referred to as “vehicle”).
2. That, on 20/05/2024 around 05:32 PM while my vehicle was
proceeding from Sriram Colony, Kattedan towards Aramghar by
Kattedan Industrial area met with an accident with Activa3G Scooter.
3. That, at the time of accident vehicle was driver by Gummalla Saurav
Shekar, (SON) and there were in all 1 person (including driver) persons
travelling in and / or by the vehicle.
Contd..2/P.
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4. That, in the said accident no person has sustained any bodily
injury/ies and / or died. Further the owner/s of the vehicle/s and / or
property damaged in the said accident are neither claiming any
compensation from me nor have any grievance against the driver of my
vehicle.
5. That, the accident was neither reported to any Police Station nor
any Police Authority has taken cognizance of the accident. After execution
of these presents, if any police complaint is filed and / or comes to my
notice, I undertake to notify the same to you without fail.
6. That, I clearly understand that in the event of my above statement/s
found to be incorrect and / or false and thus would have deprived Liberty
Videocon General Insurance Company Limited (hereinafter for the sake of
brevity be referred to as the “insurer”) of immediate opportunity to
investigate into the matter, would be considered as breach of duty on my
part as envisaged u/s 134 (c) of Motor Vehicle Act, 1988 r/w condition 1 of
the Policy and in that case insurer will be well within its authority to
disclaim all and / or any kind of liability/ies towards any such claim/s
raised by third party/ies including but not limited to recovery of amount
paid to me towards my own damage claim.
