Format of Affidavit for Consumer Case for Vehicle Insurance Claim
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BEFORE THE PRESIDENT DISTRICT CONSUMER
DISPUTES REDRESSAL FORUM, _____, _____
Complaint No._____ of _____ Under
Consumer Protection Act
_____
…..Complainant Versus
_____
…..Respondents
Complaint under section _____ of the
consumer Protection Act, _____
EVIDENCE
BY WAY OF AFFIDAVIT OF THE COMPLAINANT
I,
_____ son of _____ resident _____ at present Resident of _____ do hereby
solemnly affirm and declare as under:-
1- That the deponent is the consumer of
the respondent as defined under the consumer protection Act, _____.
2- That the deponent is the registered
owner of the vehicle _____ bearing its Registration No. _____ Engine No. _____,
Chassis No. _____, Model _____. The said vehicle was get insured by the
deponent with the respondent insurance company vide insurance policy No. _____
which was valid with effect from _____ to midnight of _____ covering all type
of risks therein. As per the insurance policy issued by the respondent to the
deponent , the said vehicle was get insured for the amount of _____/- (_____) . A photocopy of the
insurance policy and a photocopy of Registration Copy of _____ No. _____ are
exhibited herewith as _____.
3- That at the time of issuance of the
above said insurance policy, the respondent had assured the deponent that the
respondent would pass insurance claimed and make the payment of the claimed
amount immediately, if the said vehicle will meet with accident or will be
stolen at any point of time with in the
validity period of the said insurance policy .
4- That in the mid night of _____ at
about _____. The deponent parked his above said _____ in front of _____ in
_____, but the said vehicle was stolen by someone in the night of _____. The
deponent searched the said vehicle everywhere, but the where about of the said
vehicle were not traced by the deponent. Hence the deponent got registered the
FIR in the police station _____ bearing its FIR
No. _____, dated _____ U/S. _____IPC regarding the theft of the said
_____ against unknown thief. The copy of the FIR is exhibited herewith as _____.
5- That just after the steeling of the
said vehicle of the deponent intimated the respondent and also submitted the
FIR and all the relevant documents to the respondent regarding the steeling of
the said vehicle.
6- That then after the deponent
approached the respondent and requested to make the payment of the insured
amount by raising the insurance claim in the office of the respondent. In this
regard the respondent had issued the claim no. _____ and the respondent demanded
the copy of the untraced report or final
report from the deponent on _____.
7- That upon the application of the
deponent the Hon’ble court of _____, has declared the above-mentioned vehicle
as untraced vide its order dated _____.
The copy of the order dated _____ is exhibited herewith as _____.
8- That then after the deponent
personally visited the office of the respondent and met with the respondent and
again approaching for claim in writing and submitted the final report along
with the copy of the untraced report, photocopy of insurance policy , copy of
the FIR, NCR Report, and copy of the
R.C. of the said vehicle vide application dated _____.
9- That the respondent being the insurer
of the above mentioned vehicle of the deponent and the above said vehicle has been stolen in the validity
period of insurance policy, hence the respondent is liable and duty bound to
pay the insurance claim as per the terms and conditions of the said policy to
the deponent as soon as, but the respondent is trying to escape from their
responsibility and liability to make the payment of the claimed amount to the
deponent in arbitrary manner, hence the deponent is legally entitled to recover the amount of
insurance claim along with interest from the respondent as per the terms and
conditions of the insurance policy
.
10- That the cause of action to file the
present complaint accrued on each and every date when the deponent requested
the respondent to make the payment of the insurance claimed amount and the
cause of action finally accrued on _____ when the respondent has finally
refused to make the payment of the insurance claimed amount to the deponent.
11- That the relevant documents which are
produced before this Hon’ble Forum may kindly be read in my evidence.
Deponent
Verified
that the above contents of this affidavit are true and correct to the best of
my knowledge and belief and nothing has been concealed therein Verified at
_____ on _____
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