Certificate No.
_______________________________ Dated ________________
Affidavit
Affidavit of Anuj Yadav S/o Sh. Satyavir R/o H.No.88 Sadhwada Khaira, South West New Delhi -
110043. I the above-named deponent do hereby solemnly affirm and declare as under: -
That I am the owner of car Maruti Ertiga VXI CNG Registration No. DL3CCV3032 Bearing Chassis
No. MA3BNC22SML412831 or Engine No. K15N9211444 which is comprehensively insured with
M/s Reliance General Insurance Co. Ltd. vide cover note no. /Policy no. 991792223740001994 for
the period from 19/01/2022 to 18/01/2023, claim intimated and claim no./ref. no. ______________
That at the time of accident Lalit Yadav S/o Sh. Sudesh Yadav driving the car bearing License No.
DL0920080134000 dated 19/07/2011 or expiry date of License 03/04/2028, Auth. to drive LMV-NT
+ M.CYL.
That the said car met with an accident on 05/12/2022 time 03:00 PM at on Timar Pur, Delhi
causing damage to the car in this cause my car hit with front side which a claim lodged with the
insurers, No FIR/NCR is registered in this case in any Police Station and no third-party claim is
made. No. injury to anybody if any third-party claim is received the same shall be intimated to the
insurers for further action.
Deponent
Verification
Verified that the contents of the above affidavit are correct to my knowledge, no part of it is false;
nothing material is concealed there from.
Verified and signed at Delhi
Deponent
