To,
Infinity Assurance Solutions Pvt. Ltd.
On behalf of Future Generali India Insurance Company Limited
24, US Complex, Adjacent to Jasola Apollo Metro Station,
120, Mathura Road,
New Delhi - 110 076 (India)

SUB: Mobile Claim Reimbursement - Policy / CoI Number : Claim No. M0229815 Ticket No. 112021/67169

Dear Sir,

I, JAMPAIAH VELIKATTE have incurred expense of Rs.7335.00 (Rupees Seven Thousand Three Hundred And Thirty - Five Only) towards Repair of my VIVO V21 5G 8 128G Mobile - Smart Phone IMEI / Sr. No. 869141056515150 insured with Future Generali India Insurance Company Limited under FG Mobile All Risk Insurance Policy having Certificate of Insurance No. (reference Loan No.43634286) registered against your Ticket No. 112021/67169 (Claim No. M0229815).

I understand that the payment towards my claim shall be as per above mentioned insurance policy and is subject to deductions / excess charges of Rs. 734.00 and any other deductions as may be applicable and the expenses mentioned above are not actual claim charges.

I also understand that the final settlement amount is subject to available balance Sum Assured of Rs.29990.00 or as may be evaluated as per my Insurance Policy, and previous claims if any.

I declare that

I have actually incurred these expenses, and this is my full & final reimbursement against above mentioned claim details.
I understand that the actual claim amount payable to me is subject to verification and re-calculation at your end.
I have not sought or claimed these expenses from any other party or insurer
I will not claim these expenses from Future Generali India Insurance Company Limited
The details shared by me in this request are correct & complete to the best of my knowledge and belief; and I take full responsibility of any consequences arising out of any incorrect or false or unclear information shared by me in this Request or during processing of abovementioned claim.
I hold you i.e. Infinity Assurance Solutions Private Limited and Future Generali India Insurance Company Limited indemnified against any delay or non-payment due to incorrect or false or unclear information in this form or during processing of my abovementioned claim.
I understand that it may take a few business days for payment to reflect into my account from the date of submission of a valid request

You are requested to reimburse the claim amount to my Bank account (detailed below):

Bank Account No.

Confirm Bank A/c No.

IFSC Code

Bank Name

Bank Branch

Bank Address

Account holder Name

Account holder Address

Amount Payable to Me

Customer Name	Beneficiary Name	Account No.	IFSC Code	Bank Name	Branch
JAMPAIAH VELIKATTE	VELILATTE JAMPAIAH	6234 8916 629	SBIN0 02084 8	STATE BANK OF INDIA	UPPAL BR

Select + Submit Supporting Documents regarding Your Bank Details (documents already submitted are showe below):

Sr No.	Open	Document Title	Submission Date	Document Status
1		Claim Reimbursement Request Form	09/Nov/2021 11:45 AM	Approved
2		Bank Passbook Copy	06/Nov/2021 05:50 PM	Approved

Submit Documents for your Claim through the link ---->>

https://s.infyshield.com/s.aspx?t=67169-5qm