SDP-25 Pads x50-01/18

LIC LIFE INSURANCE CORPORATION OF INDIA

execution
Form No. 3762

(To be stamped RS...

.senan t the Stamp Office before
or to be copied out on a Non-Judicial stamped paper
for equal value)

******************'************************************************"******"
TO ALLTO WHOM these presents shall come
(Full Name and Address)

*****°°**********°****°*********"***********************************************************************************'*************** *******

of the Policyholder, Assignee and Surety)

* * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * ° v * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * " * * * * * * * * * * ° * * * * * * * * * * * * * * * * * * * * * * * *

***********°****************************************************************************************************************°***************°********

Indurance Numbered
*******esesos*eesseseseaese****

Greetings WHEREAS a Policy/Policies of

. . .

inhabitants send

******************°******°**********°'***"
was/were granted
***********************************************************°******* r Rs

of India (hereinafter
* * * * * * * * * * * ****' *
* *
* *
* *
* ***"
*****
* * * * * * * * * * * * * * * * *
***********************
by the Life Insurance Corporation
******************************************2************************************ ***

referred to as the Corporation) on the Life No. (Full Name of the assured)
*********************************e********************************.****************************************.
AND WHEREAS on the said KName of the Policyholder)

****************°*****°* **********************************************°**********°*******

No.
solemnly affirming that the said Policy
.

**********°****************************************************************°*******************************°****°**********
which was/were lost.
circumstances of loss)
(Brief statement of the
of
for any assignment, Notice
dealt with in any other manner except or
was/were not assigned, mortgaged to return to the Corporation
the
to the Corporation and undertaking
which may have already been given WHEREAS the said Corporation has
recovered subsequently AND
on the Policy
duplicate if the original Policy is/are
**************************************************.********.********.******.********************************************************
and Surety)
(Name of the Policyhleder, Assignee
******************"*****"*"************************"********************************""***********************************************************************"***********************
to
nature hereinafter appearing agreed
the said Corporation a Covenantof the
enter into with
undertaking to *****************************************************.*************************.**** *****************

said..
issue to him the
(Name of Policyholder)

**********************************°******'*****************************************"""*******'***'°**'****************************************** ... ..

****************************e**************************************""******""************
the duplicate of the said Policy No . NOW KNOW HE
**********s**n**********************esoennses*n*************
the duplicate of the said Policy No. of the and in consideration
of the said agreement
AND THESE
PRESENTS WITNESS that in pursuance the saici duplicate of the
of these presents agreed to issue
Corporation having or at before the execution
said Policy.******"*******************°*******************************************e******.****************************a*****************************
*************************************.****A********************.*****s*a***************************°****... they the said
to the said.
(Name of Policyholder)n

sald Corporation, its

Covenant with the
do hereby for
themselves, their, heirs executors
or ******e****************************e******************************************'
administrators
***"*>***.
that they the
s u c c e s s o r s and assigns Surety)
Assiginee &
Policyholders,
(Name of
**********************************************************e***.
*************************************************************°********e***************.
their, heirs, executors or administrators will from time to time and all times save and
keep harmless and
indminified the said corporation, its successors and assigns of and from all actions,
suits, costs, claims, and
demands of whatever nature and kind so ever which may be instituted, or preferred, claimed, made against
the saidCorporation, its successors or assigns by any person or
persons by reasons of his/her or their
possession of or right to the said original
Y****.**********snsnenens**nsesens*ssseneosessssosnees*******************e******************
*************************e***********************************************************o**************ee**s***********e************************************************
by reason of anything in relation to the premises.
IN WITNESS WHEREOF the said.. ******************
*********************i******* *****************

(Name of Policyholder, Assignee

************************°***********************.********************************************e********************************************************
and surety)
have hereunto put their hands at...
*************************°°***********°*°****°*****°******e******e****°*****°******°******°*****
this..

Signed and delivered by the within named

.
.**s ** 1.
*************"************ ************************************************************
(Full Name of Policyholder)
(Signature' of the Assured)

2. *****"******°*********°°************°°************** 2.
(Full Name of Assignee) **********************************.*******e*************************
(Signature of Assignee)

3. ****************************************** 3. **************************e******e******e***************************
(Full Name of Surety)
(Signature Surety)

In the presence of
: 1.
1. Witness Occupation of Assured. ***°********°*******..

Signature...
**********.********************es*******.o** Address ***********************a***********************
Full Name..
***********************************e***************
Occupation.
IU.....************************************************ 2. Occupation of Assured ..********.*******************
Address .e****************eo*********************************** Address..**************************************************
*************************°e******************°**************°*******

3. Occupation of Surety .******************************

Address...********ee*****..********e**********************
2. Witness
Signature..******°**************************************
Full Name. s********************************* ***********
Occupation..***********************************************
Address..
********************°°*************************************
******************°*
******************°e**************.

3. Witness
Signature..****************°*************************************
Full Name..
*************************e************ ******o*****
Occupation... ***************************************
HadreSS....... .**o***************************************
************" *********************

Note If this Bond is signed in Vernacular one

of the attesting
that the contents of this Bond were explained to the witnesses should be requested to certity
party in Vernacular before execution