LETTER OF SUBROGATION THE NEW INDIA ASSURANCE CO. LTD.

BO/DO __________________ ADDRESS Dear Sirs, Re: Claim No.______________________ Policy No.______________________ I !e"e#! Co$e"e%________________

We herby acknowledge receipt of the sum of Rs._______________ R!"EES _______________________________________________# which you ha$e paid to us and which we ha$e accepted in full % final settlement of our claim in respect of the claim preferred by us for loss of property occurred due to ____________________ on ________________________. We further declared and agreed that by $irtue of the aforesaid payment the underwriter concerned became subrogated to all our rights, interest and remedies in respect of the aforesaid sub&ect matter in accordance with the laws go$erning the contract of insurance. We also declare and agreed that the said 'ew (ndia Assurance )o. *td. Shall ha$e une+ui$ocal rights and authority to use our name to the e,tent as may be necessary to effecti$ely e,ercise all or any such rights and or remedies that we will furnish them with any assistance they may reasonable re+uire of us when e,ercising such rights and whilst on their part they will indemnify us against liability for costs, charges, e,penses arising our of and in connection with any proceedings which they may initiate in our name in e,ercise of such rights and remedies. DATED THIS ______________ DA& OF __________ '( _______ AT _________________.

INSURED)S SIGNATURE: INSURED)S NA+E: INSURED)S ADDRESS

NOTAR& PUBLIC)S SEAL * SIGN

WITNESSED B& SIGNATURE NA+E ADDRESS