INDEMNITY BOND

This bond of indemnification is executed on 19-10-2019.

I ANANTRAJ U NAYAK S/O. UMESH NAYAK R/O. H.No.653, Near Convent Primary School,
Township, Dandeli, Uttarakannada, KARNATAKA – 581325 Holding PAN No. ADNPN0356L Aadhar
Number 231485443551 engage for myself, Successor, Executors Administrators and assigns to hold
responsible for indemnification to M/s.Universal Sompo General Insurance Co. Ltd., having its
registered office Unit No. 402, Sangam Complex, Andheri Kurla Road, Andheri East, Mumbai,
Maharashtra [hereinafter referred as USGI] and its Directors and officers, Successors and assigns
harmless and indemnified against the suits, actions, proceedings charges, damages, demands, cost,
losses and expenses which may arise from any claim, action, liability, loss, damage or suit arising out
of payment of Rs.13700/- which was deposited by mistake in the Bank account of USGI.

I hereby solemnly affirm, declare and undertake,

1. That, I, by mistake deposited cash amount of Rs.13700/-i.e., Rupees (in words) Thirteen
thousand seven Hundred only in the Bank Account No. 510341000049732 of Corporation
Bank, Santacruz Branch, which belongs to M/s. Universal Sompo General Insurance Co. Ltd.,
and operated solely by USGI.
1. That, the aforesaid amount was deposited without any intention of making payment of any
nature to M/s. Universal Sompo General Insurance Co. Ltd., or with the intention of creating
any liability in present or any future liability. The amount so deposited belongs to me only
and I deposited the amount on behalf of myself only. The amount so deposited has no
connection with any premium related to any Policy or Cover note or any proposal submitted
to M/s. Universal Sompo General Insurance Co. Ltd., or any recovery demand raised by
Universal Sompo General Insurance Co.Ltd.,
2. That, the amount as stated above was deposited in the above noted ban account of M/s.
Universal Sompo General Insurance Co. Ltd., solely by mistake and is not related to any
insurance premium or insurance coverage of any Motor Vehicle or Property or Liability or for
the coverage of any other insurance of any type of Risk or liability or any recovery raised by
M/s. Universal Sompo General Insurance Co. Ltd.,
3. That, M/s. Universal Sompo General Insurance Co. Ltd., shall not be held responsible for any
type of claims, including any third party liability arising out of the amount deposited in the
bank account as stated above.
4. That, I hereby declare and undertake that M/s. Universal Sompo General Insurance Co.
Ltd.,or its Directors and Officers, successors and assigns harmless and indemnified against all
suits, actions, proceedings charges, damages, demands, cost, lossess and expenses which
may arise from any claim, action, liability, loss, damage or suit arising out of payment.
5. I hereby raise a request to M/s. Universal Sompo General Insurance Co. Ltd.,to refund
Rs.13700/-i.e., Rupees (in words) Thirteen thousand seven Hundred only deposited in their
aforesaid Bank account which was deposited by my mistake.
6. That I am giving hereunder the details of Bank account which is solely operated by me, with
request to transfer Rs.13700/-i.e., Rupees (in words) Thirteen thousand seven Hundred
only in the bank account given below:
Name of Account Holder : ANANTRAJ U NAYAK
Account No. : 03072200037224 IFSC Code SYNB0000307
Name of Bank : SYNDICATE BANK Branch Name DANDELI – 581325
(banks cancelled cheque to be attached)
I hereby affirm and declare that the statement given above are true and correct.
Signed _____________________________________
Full Name : ANANTRAJ U NAYAK
Full Address : H.NO. 653, Near Convent Primary School,
Township, Dandeli, Uttarakannada
Phone No. : 9448530567
Date : 19-10-2019

1. Witness (Signature)
Name
Address
2. Witness (Signature)
Name
Address