Claim Settlement Form (CSF)
Emirates Ref: DXB/X/MF/011125/8343247 Baggage Claim Ref: None
CCC: 52021 - 55011 - M452
Release and Discharge Receipt
I, Mr Gaurav Patel, born on 18 June 1995 and domiciled at the address mentioned below hereby acknowledge receipt of the
settlement offer dated 16 December 2025 in respect of the settlement of any possible claim against Emirates, a Dubai corporation
established by Decree No. 2 of 1985 (as amended), having its principal place of business at Emirates Group Headquarters, P.O.
Box 686, Dubai, United Arab Emirates, arising out of the following incident: Damaged baggage on Emirates flight EK241 from
Dubai to Toronto on 1 November 2025.
I am satisfied with the above mentioned settlement offer and, in consideration of the payment of INR7500.00 (Indian rupees
seven thousand five hundred only) on the bank account mentioned below, I hereby agree:
a) To unconditionally and irrevocably release and forever discharge Emirates and its employees, and/or its subsidiaries,
associated and affiliated companies and their respective directors, servants, agents, insurers, reinsurers and assigns
(together the “Related Parties”) from any and all actions, claims, rights, demands and liability, known or unknown,
arising out of or connected to the Incident;
b) To indemnify Emirates and the Related Parties (as in (a) above) in respect of any further claims that may be made
against them arising out of the Incident; and
c) Not to sue Emirates or the Related Parties (as in (a) above) in relation to the Incident.
I furthermore confirm that this settlement does not constitute any admission of liability by Emirates. I have not been compelled
in any way to sign this release and I have entered into this agreement freely and of my own accord and I would ask all concerned
to note that I now regard this matter as having been concluded to my satisfaction.
Bank Details
NRO or domestic account only. Emirates is unable to process payments to NRE bank accounts in India. Bank account must be in the
name of the passenger. To avoid any mismatch at bank level, please provide your details as per your bank account.
*Name of account holder:
*Account number:
*Account type: ☐ CACC - Current Account ☐ SVGS - Saving Account
*Account currency:
*Bank name:
*Bank branch address:
*Bank country:
*IFSC:
*SWIFT code:
Passenger Address and Contact Details
*Mailing address:
*Contact number:
*email:
Passenger Name and Signature
*Name(s):
*Signature(s):
*Date: / /
Note:
*mandatory information
Please provide your complete mailing address including building name and/or number, street name, city, post code, country, PO box etc.
CASA VS3 28012025
BUSINESS DOCUMENT This document is intended for business use and should be distributed to intended recipients only.
