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

ONLY FOR NOMINEE PURPOSETO BE NOTARIZEDOn stamp paper of Rs. 200AFFIDAVIT CUM INDEMNITY (For Claim purposes)I, _____, son/daughter/wife of ____, aged about ____years, Indian Inhabitant,residing at _____ do hereby solemnly state, declare and affirm as under:i. I say and declare that, Mr / Mrs. ____________ (the “deceasedpolicyholder”) was and is the bonafide policyholder of the subject policy.ii. I say and declare that on ________, the said deceased policyholder made theproposal for the ________________[Name of the Plan] from Kotak MahindraOld Mutual Life Insurance Limited (erstwhile known as OM KotakMahindra Life Insurance Company Limited) having its Registered Office at8th Floor, Godrej Coliseum, Lokmanya Pan Bazar, Behind Everard Nagar,Sion (E), Mumbai 400 022 (“Kotak Life Insurance”) under a proposalapplication form bearing policy number________.iii. I say and declare that subsequent to the aforementioned Application, KotakLife Insurance issued the policy contract bearing number ________ (the“said Policy / said Original Policy contract”) was issued and dispatched tothe deceased policyholder.iv. I say, declare and confirm that I am the nominee appointed under the saidPolicy and hence acquired the right to make the claim before Kotak LifeInsurance on behalf of the policyholder.v. I hereby say, declare and confirm that, the said Original Policy contracthave lost / misplaced which was issued to the said deceased policyholderand is no longer available with me.vi. I say that I have tried to locate the same to the best of my efforts and amunable to do so and have despaired of locating the same. .vii. I say and confirm that at my request and based on the aforesaidrepresentation, Kotak Life Insurance have agreed to waive the condition ofsubmitting the said Original Policy contract against furnishing thisAffidavit-cum-Indemnity.viii. I say and declare that in the event said Original Policy contract is located, Iagree to forthwith return the said Original Policy contract to Kotak LifeInsurance immediately without any delay.

ix. In consideration of non-submission of the Original Policy contract, I herebyindemnify and undertake to continue to hold Kotak Life Insuranceindemnified and harmless from and against any payment that may be madeand/or any loss, damage or costs (including any legal fees) that maysuffered and/or incurred by Kotak Life Insurance towards in respect of theOriginal Policy contract.x. I say that the above submissions and declaration are true and no portionthereof is false and I have concealed nothing material or relevant to thematter.xi. Any stamp duty payable on this Affidavit cum Indemnity shall be theresponsibility of and shall be borne by the Deponent alone.Solemnly affirmed as aforesaid at ______This ____ day of _____, 20____DeponentBEFORE ME