Discharge Voucher ACCIDENT DEPARTMENT
Claim No.___________
The Oriental Insurance Company Limited
Head Office, A-25/27, Asaf Ali Road, New Delhi-110 002
Received__________________________________Day of __________200_____
From THE ORIENTAL INSURANCE COMPANY LIMITED, the sum of Rs._________
(In words Rupees_________________________________________________________)
in full and final settlement of the loss and/or damage caused through the accident to
my/our motor Car/Vehicle No.______________ insured under Policy No._________ of
the said company and accident which occurred on or about _______________I/We give
the discharge receipt to the Company in full and final settlement of all my/our claims
present of future arising directly/indirectly in respect of the said accident.
Rs._______________
Witness Signature …………………………..
Name ……………………….. Occupation ………………………...
Signature …………………... Address ……………………………
…………………………….
Address ……………………. …………………………….
Bank Account Number …………….
Name of the Bank ………………….
One Rupee
Revenue Stamp
When Amount
Exceeds Rs. 5000/-
Issuing
Office