Affidavit cum Indemnity in case of lost policy document - Kotak Life ...

ONLY FOR NOMINEE PURPOSETO BE NOTARIZEDOn stamp paper <strong>of</strong> Rs. 200AFFIDAVIT CUM INDEMNITY (For Claim purposes)I, _____, son/daughter/wife <strong>of</strong> ____, aged about ____years, Indian Inhabitant,resid<strong>in</strong>g at _____ do hereby solemnly state, declare and affirm as under:i. I say and declare that, Mr / Mrs. ____________ (the “deceased<strong>policy</strong>holder”) was and is the bonafide <strong>policy</strong>holder <strong>of</strong> the subject <strong>policy</strong>.ii. I say and declare that on ________, the said deceased <strong>policy</strong>holder made theproposal for the ________________[Name <strong>of</strong> the Plan] from <strong>Kotak</strong> Mah<strong>in</strong>draOld Mutual <strong>Life</strong> Insurance Limited (erstwhile known as OM <strong>Kotak</strong>Mah<strong>in</strong>dra <strong>Life</strong> Insurance Company Limited) hav<strong>in</strong>g its Registered Office at8th Floor, Godrej Coliseum, Lokmanya Pan Bazar, Beh<strong>in</strong>d Everard Nagar,Sion (E), Mumbai 400 022 (“<strong>Kotak</strong> <strong>Life</strong> Insurance”) under a proposalapplication form bear<strong>in</strong>g <strong>policy</strong> number________.iii. I say and declare that subsequent to the aforementioned Application, <strong>Kotak</strong><strong>Life</strong> Insurance issued the <strong>policy</strong> contract bear<strong>in</strong>g number ________ (the“said Policy / said Orig<strong>in</strong>al Policy contract”) was issued and dispatched tothe deceased <strong>policy</strong>holder.iv. I say, declare and confirm that I am the nom<strong>in</strong>ee appo<strong>in</strong>ted under the saidPolicy and hence acquired the right to make the claim before <strong>Kotak</strong> <strong>Life</strong>Insurance on behalf <strong>of</strong> the <strong>policy</strong>holder.v. I hereby say, declare and confirm that, the said Orig<strong>in</strong>al Policy contracthave <strong>lost</strong> / misplaced which was issued to the said deceased <strong>policy</strong>holderand is no longer available with me.vi. I say that I have tried to locate the same to the best <strong>of</strong> my efforts and amunable to do so and have despaired <strong>of</strong> locat<strong>in</strong>g the same. .vii. I say and confirm that at my request and based on the aforesaidrepresentation, <strong>Kotak</strong> <strong>Life</strong> Insurance have agreed to waive the condition <strong>of</strong>submitt<strong>in</strong>g the said Orig<strong>in</strong>al Policy contract aga<strong>in</strong>st furnish<strong>in</strong>g this<strong>Affidavit</strong>-<strong>cum</strong>-<strong>Indemnity</strong>.viii. I say and declare that <strong>in</strong> the event said Orig<strong>in</strong>al Policy contract is located, Iagree to forthwith return the said Orig<strong>in</strong>al Policy contract to <strong>Kotak</strong> <strong>Life</strong>Insurance immediately without any delay.

ix. In consideration <strong>of</strong> non-submission <strong>of</strong> the Orig<strong>in</strong>al Policy contract, I hereby<strong>in</strong>demnify and undertake to cont<strong>in</strong>ue to hold <strong>Kotak</strong> <strong>Life</strong> Insurance<strong>in</strong>demnified and harmless from and aga<strong>in</strong>st any payment that may be madeand/or any loss, damage or costs (<strong>in</strong>clud<strong>in</strong>g any legal fees) that maysuffered and/or <strong>in</strong>curred by <strong>Kotak</strong> <strong>Life</strong> Insurance towards <strong>in</strong> respect <strong>of</strong> theOrig<strong>in</strong>al Policy contract.x. I say that the above submissions and declaration are true and no portionthere<strong>of</strong> is false and I have concealed noth<strong>in</strong>g material or relevant to thematter.xi. Any stamp duty payable on this <strong>Affidavit</strong> <strong>cum</strong> <strong>Indemnity</strong> shall be theresponsibility <strong>of</strong> and shall be borne by the Deponent alone.Solemnly affirmed as aforesaid at ______This ____ day <strong>of</strong> _____, 20____DeponentBEFORE ME