ON STAMP PAPER OF RS.

200
AFFIDAVIT CUM INDEMNITY

I, _______________________, son/daughter/wife, of ______________ aged about ____ years, Indian

Inhabitant, presently residing at _____________
____________________________________________ do hereby solemnly state, declare and affirm as
under:

1. I say and declare on _______________________, I submitted the proposal for the

________________________________________ Plan from Kotak Mahindra Old Mutual Life
Insurance Limited having their Registered Office at 9th Floor, Godrej Coliseum, behind
Everard Nagar, Sion (E), Mumbai – 400022 (“the Company”) under a Proposal Application
Form bearing number_________________ (if available).
2. I say and declare that subsequent to the aforementioned Proposal Application, the Company
issued the policy contract bearing number _____________________ (the “said Policy / said
Original Policy Contract”) was issued and dispatched to us on
_________________________and the same was acknowledged by us.
3. I say and declare that the life insured on the aforesaid policy is
______________________________ son/daughter of ___________________________ aged
about _____________ years, Indian Inhabitant, residing at ___________________
___________________________________.
4. I say and declare that, I am the bonafide policyholder in the said Policy.
5. I say, declare and confirm that the said Policy has been lost / misplaced and is no longer
available with me.
6. I say, declare and confirm that I have tried to locate the same to the best of my efforts and am
unable to do so and have despaired of locating the same. I therefore request you to issue a
duplicate policy to me.

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 7. I say and declare that at my request and based on the aforesaid representation, the Company
have agreed to issue a duplicate policy contract in lieu of the misplaced / lost of the said
Original Policy Contract against furnishing this Affidavit-cum-Indemnity.

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8. I say and declare that in event of the said Original Policy Contract is recovered or found, I
agree to forthwith return the same to the Company immediately, without any delay. I further
confirm and declare that the duplicate policy contract will not be misused. Failure to return the
same, shall amount to breach of contract.
9. In consideration of the Company issuing a duplicate policy contract, I hereby indemnify and
undertake to continue to hold the Company fully indemnified and harmless from and against
any payment that may be made and/or any loss, damage or costs (including any legal fees) that
may suffered and/or incurred by the Company towards issuance of the duplicate policy
contract and /or towards or in respect of the said Original Policy Contract.
10. I say that the above submissions and declaration are true and no portion thereof is false and I
have concealed nothing material or relevant to the matter.
11. Any stamp duty payable on this Affidavit cum Indemnity shall be the responsibility of
and shall be borne by the Deponent alone.

Solemnly affirmed as aforesaid at ______

This ____ day of _____, 20____

Deponent

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BEFORE ME