Letter of Subrogation & Irrevocable Special Power of Attorney

(To be executed by the insured/beneficiary)

Space for Stamp

(Rs. 100/- Stamp)

To:
Reliance General Insurance Company Limited
_____________________________________
_____________________________________
_____________________________________

In Consideration of your paying to us a sum of Rs._____________________ (in words)

_____________________________________________________________ in respect of
loss/damage to our property, viz.<HP Make Laptop S.no………… purchased vide invoice
no……….. dated…….. due to Theft/ Burglary on __/__/____ insured under policy no/
certificate no. _____________________ issued by Reliance General insurance Company
Limited, we hereby assign, transfer, and abandon to you all our actionable rights, title and
interest in and to the said good and proceeds thereof (to the extent provided below) and all
rights and remedies against person(s) who so ever is/are liable in respect thereof.

We hereby guarantee that we the persons entitled to enforce the terms of contract of insurance
and agree to indemnify you for all and any losses and consequences should it turn out that we
are not the persons to enforce the terms of the contract.

And we hereby subrogate to you the rights and remedies that we have in consequence of or
arising from loss/damage to our insured goods and we further hereby grant to you all power to
take and use all lawful ways and means to demand, recover and to receive the said
loss/damage and all and every debt from whom it may concern.
And we also hereby authorize you to use our name in any action or proceedings that you may
bring either in your own name or in our name in relation to any of the matters hereby assigned,
transferred and/or abandoned to you and we undertake for ourselves to assist and concur in
any matters of proceedings which you may deem expedient or necessary in any such action or
proceedings and to execute all deeds, assignments and/or documents including any and all
pleading and releases which may be necessary therefore and generally to assist therein by all
means in our power.

We further agree that any monies collected from any person or persons, shall be your
property, and if received in the first instance by the undersigned, we undertake to make over to
you immediately the amount so received.

We hereby further agree that in the event of lost package and/or contents thereof subsequently
being traced, we undertake to accept and take delivery of the same and the claim shall then be
readjusted on the correct basis of the then loss/damage and in the event of any refund proving
to be due to the underwriter, we on our own shall make such refund to you.

We authorize you to generally to do and execute all such other matters, acts and things as
may be necessary for the purpose aforesaid as fully and effectually as if we were present and
had done it and we hereby agree to ratify all the said attorneys and substitutes shall do and/or
cause to do, be done jointly or severally in the execution of the premises herein.

In witness whereof we have executed this document and have set our hands and seal here
unto at ____________________ this _______________ day of _______________

SIGNED, SEALED and DELIVERED by

In the presence of _______________________________

Before me identified by me

Cause of loss & Magistrate or

date thereof Notary Public Advocate