CPW 100P x 100L PSF 31/10-11 Form No.

3756

1100
---1
~1llltl!IR'1fn:rrfll"rT1'!'
Ufa Insurance Corporutlon of lndla

1·- -- - -- - -- - - - - - -- --- - - - - --- -·· -

(To be stamped with Rs .. .... .. ... ... .. .. ..... at the stamp
Office or Collector's Office BEFORE EXECUTION, orto
be copied out on a non-judicial Stamped Paper of equal
______ _ ___ ___ __ _________ ____ ____ _J
1value.)
~ -- - t.\ tu-.+· .-\.A..tt-MI ->
'3/
TO ALL TO WHOM these presents shall come

··· ········ ······· ········· ······· ··· ·· ··· ····· ······· ······ ·· ······ ··· ······· ··· ·· ··· ······ ·············· ··· ··· ··· ···· ····· ··· ····
(Full names and addresses of the Policyholder, Assignee and Surety)

··· ·· ········ ··· ·· ··· ····· ·· ······ ·· ·· ··············· ····· ···· ···· ····· ·· ······ ···· ·· ········ ·· ··· ···· ······•·· ··· ·· ···· ··· ···· ··· ·

···· ·· ··· ····· ···· ···· ····· ····· ·· ·· ······· ··· ··· ·· ····· ··· ······ ······ ·········· ····· ···· ···· ···· ···· ··· ··· ······· ··· ··· ····· ··· ·

inhabitants send Greetings WHEREAS a Policy of Insurance Numbered .... ..... .. .... ... ... ...... .

for Rs. .. .. .... ...... .... .... .. .... _.. ... .. .. .... .. ... was granted on . .. .. .. .. .. .. .. .. .. .. .. .. .. .. . . .. by the

LIFE INSURANCE CORPORATION OF INDIA (hereinafter referred to as the

Corporation), on the life of ... .... ......... .. ....... ... ... ............ .. ..... . AND WHEREAS the said
(Full name of Assured)

Policy No. ....... .... .. ... .. .. .. ..... ... .. .... ... which was in the possession of .... ... ..... .. .... ..... ... _

...... .. .. .. ... ...... .. .... .. ......... .. .......... .. ... has been lost or misplaced. AND WHEREAS the

said Corporation has on the said ..... ... ..... ..... ... ... ............. ..... ...... .. ..... .. ....... .. ... ... .. ... .. ..
(Names of Policyholder, Assignee and Surety)

········ ···· ····· ··············· ····· ·· ··· ·· ······· ····· ·· ·········· ·· ····· ··· ·· ···· ····· ··········· ···· ··· ··· ···· ··· ······· ·······
undertaking to enter into with the said Corporation a Convenant of the nature hereinafter appearing

agreed to issue to him the said .. ... .......... ........... ..... .. ...._.: ........... .. ......... .. ........ ...... .. .............. .. .. ... ......... .
· (Names of Policyholder, Assignee and Surety)

the duplicate of the said Policy No ..... .. ...... ..... ...... NOW KNOW YE AND THESE PRESENTS

WITNESS that in pursuance of the said agreement and in consideration of the said Corporation

having at or before the execution of these presents agreed to issue the duplicate of the said

Policy No ... ...·..... .... ..... ..... .. .. ... ..... to the said ........ ............................... ... ... ... .........................................
(Names of Policyholder)
 /

they the said ············································································································

(Names of Policy holder, Assignee and Surety)

···································································································································
····························································································································· ·· ····
do hereby for themselves, their heirs, executors or administrators Covenant with the said /

Corporation, its successors and assigns that they the said ·(a ........,M·r·... ii.l ......... , .........d.,,.,.... ::.i·
,~ames o r-o icy oder. Assignee an .::,ure,y

......................................................................................................................... their heirs, executors or

aministrators will from time to time and at all times save and keep harmless and indemnified
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, preferred, claimed
or made against the said Corporation, its successors or assigns by any person or persons
by reason of his, her or their possession of or right to the said original Policy
No ......... .. :........................................................ and by reason of anything in relation to the premises.
IN WITNESS WHEREOF the said .............................................................................. .......................... .
(Names of Policy holder, Assignee and Surety)
···················································································································· ···············
······························································································· ·············· ·· ······· ·············
have hereunto put their hands at ......................... this ..................... day of ..................... 20

Signed and delivered by the said (1) .................................................................................... ..

(name of policyholder)
(2) ................................. .................................................... .
(name of Assignee)

(3) ..................................................................................... .
(name of surely)
in the presence of :-
1 .....................(P~ii~yh~i~i~~:s. si·
9~~i~~~i....................... .
WITNESSES:
,
Full signature of Witness ........................... .. 2
Name ......................................................... ..
· ······················(;..·~siii~~~:s· si·g~~t~~~i. ·························
3. Full signature of Witness .................................. ..
Designation ................................................. .
Address ................................. ...................... . Name ....... .. .........................................................

······································································ Designation .............. .. ............................. .......... ..

Full signature of Witness ........ ..................... .
Address ............................................................. .
Name ........................................................... .
Designation .................................................. . ·············································································
Address ............... ....................................... .. .

·······································································
. Note : If this Bond i~ signed in any Re~ional Language one of the attesting witnesses should be requested
to certify that the contents ofth1s Bond were explained to the party in the Regional Language before execution .
 l
1
! .

.. 1'..·.; .:
. I..) 1Vlt;,,t ef(nr'l_.•; h,,vr. l)~·,.;,_,u~rJ rt'.h· ~,:.:1ce oi.ii;{lf~;.1~9l!.r.y(
. .,.
1
. . ·.', ! •

., .\i·..~,'.-,:· ', . .,-

. , : '· ; ' , _-. ;~- • . •

;·:,, ' ; ;
~ ,,.

f ,1 j. 1<I(( ' '.'I'.- I~ , 11" '"" iI,, 11 , ,, :,1, "I ,11,,11 i sc,-,,.,o~,· .v._1U•- o~\~;~,11~•f ,.ff~. ~d[j~j, elirlfor!
.• . -~: :_: ··• ..

~.i) .. l;;I 11:l1.1.$e l;,1~1

1
l 'i:l;~1 / 1.1:1:,!lj 11. ;.~U!iVr.rl~~y me r ron1 :u:;~ ··rniur~'1ic~:ctirn9ratioo·Q(itidlit(lf
,. ,1,n·1 · . . · . · ·.. . . · . · ·· .·.. ·: ·\ ...· :. :/ ::; ·· · ,... ·· ·· ·

.,, "'•:P.1.•y ded:11 ,, 1,ha' u".'h· !'''. '«:o,,:,~lloJ1 i; (r.~ t6_ ~{ri~~\~Mia64~~~Jilt ,. ' .
lr1s•,ll'n/lc;P. Coq.1c1l'i1 l.1011 o(·/nrl,,'1 1,(/· lr.~l.JP.' Dv;=.11 knte ·po:l)cy {lr-:iet.t\e- fH~•cfalrn/··svr,r:e:Ji'cfe1; valoe .. ..
}YI 1: I1o,1:,1: rirh~r\1i1 I1 i(:y ~io,.:1 /IW)l.1't. · J-:i rii renr.ly/to exer;1lt~{rn~~1~n·i'tfb,bhd'.,dli~iJtofar.#e-~)\b,d't,.
J),(1(

~}_:,t' }•.i.,.
,:1(~1'.I 1:cn1.J.y ·t6 ,::.i. 11n1lf:"'t~ i)l.11(:!I !'P.1,rdtr~rnahi:.~.' . .. . ' ,•. ., . ,· ' . ' :' . :.::, ·'.; .. .·. :··: ··:.· .'

...o,,,.;,,, •,,,... :;.. .· . ,,,,, .. ;.,.,.~r--.·.·.. ':·:··;-iq9{:~\•.

V ii ljrt~~;.. ., ., ... , S!g_li~J~r(~f;\f~(fijt~$l'.e~f/. . . ' :,
,,::_;Ii'(/{~/;;~-; .· \: :·/Q~!~!~t:i::·J!!t:~f\t ; ,,;.:.'
0,:rupi ti,,,-,,
, . ',' ,
.. ..•..-.; '","A,dijtiii,f.:..-; .- --_:· . ·'.., .· :· <·..;
, Y:,~f'~~· 11·,: •·,• , . ,'• , · .,., · :· ·. .-.. :- ·-

Addrfo: .'. . . . . . . . .. . . :; <:': ."',!;:: ;;{:Fi\ [..-::~ :\f.

l('fl.1_ '.~Je~:'. ~~c.i~1f(Y. /fo:D.1~.i/.1\~:r.u~{oi.~.t :.~hitQ~Nfnt$¥l\~r:.~h~\Lt ~:·: ·" ·_'
1
_I 1?. /
1 :';()f I .~lf,i
JC:f
Jt\Wl~1~~s:1:_[~~TI~f.~-~tto.¢ettff~'.;tl~·& .tr~1,~;~qJ~t$!,1~~;~~:tl1~·~~~~~JJ_' :·'.i :_ •. · -_. ·.
>!.
.'1_t1_11,,r?,~!il( 11_; tJ_
I'
•. e,:p 11,i, ,) lo tho. d~d.~r ,1 l!.1fi (Oil9l,1t~1; -~~!f'}\~'l,1h,~
·_l_lh~,rll!},llt)/,1['.~.~~!or,,h1~1te_1:,_,..~r_
v~ 11111,~:riz~1B'jqll\fll('f ' ' . .· . .
1.~,- (.1.J[}y. l.ff:1_r;l1r~~D~t~li;ig 'tf;~: S:OJ.~ti~ :, >:;'-' -:. ·,.~::,./ << . .' : . '
• .1111:; ,<for•.l;1r~~rp1:1: ,.,}'})'.. l_ir.,.:\?01~i&let$-d .b.o/fp_rtji_t!~tr~9~h~.tl.ti1.q~1.~~~-.pr.~\~U.o~~~~l.1n: ·:·.· _
..~•~\-.tl~1 n1,1( 1!.- (Jf d.~~l.11) ~\~{~i•t:-rll~~l~T'O_<ffon\t 11Q.:~~~f.:. ··..:,·: \~·:<:·": _::-;\ :~~:-:.-:~:.<;_
:.\ ··'i- .: :.,:·.- \-
ti,"·', v,
, · o~"l•rn ni II bC! ·~1,icll'{l'i1\1,t1~ _rag1 Ll11 i:t \~!1~tl.dg e;, wtJ_n,
dni,e,~t~i!lfJ!l(e'.'in •~~ce ; ·....
,,r
111 tr. '1 ""' ,,1.1,,,,
~I [I ,o r:1:11,11;~1jt,, 1,,ttr_gt~IJ!o'IJlrjfV~![1A\_{'.\~it1)~~-\~i::,? _; :-: : •C : ',: :· ..
. .. , .... . . ';'.- ' .'.:;·
, '• .. -.~ •.
__ ', ;,. ' ' ,:_-..
~-
,,,. .. ,, • . . ,·.
 ' : •I -..: - . ' • • , ·. ':/ \•;;F
; ;~)}:l~:_:,~'.t•
~;>{//)\::
{ f(}f .\:9:~lt::fj;:J;:f;:;?\••//a,.•,'' ;•:,,' ',, :.·.?~i:f/~:~t ~~~?·\~:: .-; :-:.. :('?:··: .
,,: . .. . .,... ,...,o~m\ t-,io, FLSF ,.",,;:,,, -. J- .-
,:.-J:~i'ri?.:;:-: _:_·t;~::f-'./:'.~?·\:•?:Y:'(
• •i", .. ; .

I·>·1: ;':!-' .;(··~::,-

·F_ ·~ .:-~'.if':. · .,·
I.,;;. - :
, · ';, , .
,t;,·,: '_-c.f';j.$,;,~ :f:N;~~ :,~ ·= {<1.~ •~ ;~ ;~
:. (" ' . ,," l: , • '_'i •·', ,,:,• •.': ,•_r~t f// f~:;,i•,} ', :''f,1;!}~•
,
,,\ •,!'
fj'
r· · . · .. ,. .. . ·· .· ·· :;., ··.:-., 't +ititN't.~eJ'bl~t'Sl. -,-~,·- 1

.:·1.\ ,, t, '

.8e s,..N r:1~t~ .. ..: .I~.' •• t. t ,., . . . . . fif ,1 •~_... :•1"••'~

• ,!.,(•·,•\•1\ •.• f ~ •• .. ., ·, ;, l! . •.•'•1• , r:i •,•. ,,.· ~-•., tlt' 'tltf• ,.-1. ~ i ff 1i , ,, ,.. ,"~ .,,. ,..;,,.,..., , ...,.~ •• ,..{r:.- .. •• •

,. ·.·l:.-~,;' ·;, ;\; ~\ ;. -_.:. . .:·;/ :i·.,,.,:,,::· ' .:1_.·:· '.::.·:··

Re,:, pOl l'C¼, ,._i. j:~ . ',' .
: -,: .~.: :. i/;·;·:'. _
·~·r{';i;\.;::' /?,r{\'.~//.:\/j\}fi.\)~
.•~•-•·t•:•~•.•,...
:.k; ,~,:~•-J,'fr•~~.t;};\)/1:{:\fi.i/{(/
r, .~.·,,w.,),.-,, .• -.t;7.. .. ~~·;;,
~-..·
~-~~.~;:;~~~:~~;¥z~,:~it'.:~:i~~~t'.::~i~::i; JL'X·;:JMJ':'1CU
!~;t *'i;:F:
t llt . · ~· ~ '' · ... ~1,• '. \ '1 , t . .. 1<J. ! :,(• :i'f,'1'«°1"'', .,!• •., ,, ,,.,.. ,. ,,.,. t ~!• ~ " 1 ~ • -•· ,...,"'l r,,, ff .- . .. :

1
-

1·••···•••• ... .. :•····•.: .o •t• .. ··~·· \ :'.. ~•··•; , •• , ........,:·:'- ~-~-~-·':·~-!/: t •• ,!,'. • ' ' ·.· :~. :~•• 1:,-J,.~.•,'•:,\n.~'..:,'.\···:,....-:-:,.~·• ..~~l•i•,•'.'::•·.·.,·...·•,,:,:;.·•.•:·•..••.•·•·•·j•;_-,..·~i.'.,;,,},•_•_-.,:.;;:;•;; ·•
:_·,·:J°;.;, , ··: ~.,•.(
.· .. ·. ~--. . ,.,..__ .'

2 .._,:;_~ •.·- . .... . ; .: ·.....\.··,.:_

.·.:..:' .·._. , .. .·...··...·.·.. ·. ·.•···:·~.-·,_.-·,:.,... ·.·....:...:.·..•.·".··.·.: ·,·.~,-~
..,. •
~: . ~1 j_:.: J. :.:•<•· .~,'. : ;•,.•
.·:.·.:._ ,·_·._:·_·... : • , •
.--., .\ · •· • :,
,,,.- A • > • " I
. . •. •
; ...
• •' ,. . . • . . .
;.<~~•• •~•.,•~.;..~•.:.~,~;~~~/._.,; ·••••••":.--..• •:•/.,, .•:. ·•· ;,,,,

·3·

. - .. ..
·..... . ..•' ·.•···•. .· ~ .. -..: . .,.-. ._·.· ·.·..·......::...)· . . .·...·.~:~·.·:.·. ·. ·.::_·. •· . .· .' . . .-...... .. ·. · :.·•·. .. ·. •" •· ,:· ·.· ·.·•. -, · · ., . ,. -~ ;. ~- .· .·.:... .: ....· . .. . . ··. ·.·.·• ·.··.·.

:f.,;t .,,;,;:; ,.,C):::•:~:,r,;;;,::."·;.:~iL"

. :¾
: __: ,: ":....( .: _, _..\ ... _·_'.:-.:.·:. :;_.:: :o, '; ; : '· .. , . :. :.., . • ...

·': f~:i!.~
.;:_,ir:,,i _·::''. . ..,-,.•-·•"· ' (f0:~,:, ;~,1~~~ft~~;h'./1r,~~,1•<e« ·
-~
. ·,·: .

. .. ; .•· •~:-•.:·.~·• -;- . •,••,• I •• : ..-:: • ,••.. , ••, • I • ••• : .•

:~9.~U,P.?'.H9,~~~•i~~~t-~}Y~:"'. ,;: ::: ..·,. ·· ·-. · :-'

•.{CJffi'~1rS:e;
. '. ··.
~1-- Qr.. ~1;;1~b:1>,:~r
.. .·
~ni-Ql,.
..,•.· '
--·.; .' •

,I
·.·Ad-dr.e:sS··
... I ·• • o ••• •• • •
·• ' .
..
, , ; . , ·.

...•,
· .! · ., . ..... . •.·~· ••. .- . ·· : .: · , ;'" :•• ..••, : :_:,•,.~ ·-' · :· .' ', ;\, ... \ : •,•·/ .~·~:/• ,•:•: :'.":;·,~ ~·. ·,_._: .. ·· •:•,: '. :··•: _ ·-• ' .·• , • ·:- . ,'-1 ·, c· •_' ·

Th~ ·sp;~:cifn~q . $:~h~:f,w:r..e'.f~y~:$·~:.~-~te$·led~1;any.ei·~,. q·fJh·~'foHowt11m •:

_t. -~. ~~:l~.ye~:f9l~~i~t. s'0,~:.~i19·~//:. .:.·:. _. .·., . ., ....·. .
2. 'CJ,asi.L,O:fti~;er. ol tKe:• (lfe'{ris:Q;r~bo:e,;C,:9r.p·o:ra~l9J1·otJfil:d!a' ..
J., Qe_v~io-iirm~-~.t·.o~ef~'r-~:. _
l.8.~,~Jfo)~\'~ai~•is~(ij.dihf: :· ', ..
.4.. -G~iet.e{:f'f;,ffic·er:··.· ·· '. ·,•...·: .-. :·'.: , ·. .. ·. \ ,.·: ; ··-:·· ·.: .. .
s·.:·..-·~:1~~~·¢:ev.~itipm~niO.tt16~·r. ·": -. ,.". ;·{ .·.: ·'. ..
.....
.~·. -·:MagJi,tt:a·~~,;_; ·:· ... : -~:._. /:-_.·.-:i·;,·,.·?:·":-.· _.. .:. . . ·
. .
' ._·
•I • , .

~rGlu.,~·:9.n:d,.a.~;~~:e. ,.. . ... ....- ,.. . ..

7. ·. Ag·~os~t?,.'1? IP(l~.i-n·g~ to ,o:~M-~_ ..··.,
½:Any: ~t-Me/·p.~i;~on::WM;{,:·n1.a,:y, ~i{s!'.J~i~is.~~d·b1, u-$·1nJhi~{~~-Half}.
.. .
• • . '.
; ;.\·
• • I
I'•
..
..~',·.- . .
,, ,

,,
 .. ::\: ';
,' , .··
/ ---:!:!·(
./~?, ·

·~ '.·, ._;
,::,>:\ } · lrYilllD··· ~i~i•a,V1.01.1i:.1:.,t·1.. 1:; '•::;•,::.,~:::·'.~,:,;;:•lJ·f:. ·."-.: ·:·.
~f/f '.:/i:?r.~:':._".:'.){_!,;·}<~;v~ '.·•.,/_>;-;:_}{f1'~):; ·,·,.'. ?'i/ >::
1 1
._·, .: _,' at ; .,,,a:•,r- ' >,: •' '·· :· .
-=- · ·/, · ' ' ',' ,·:R:~l.~-:•' ..,.••~-•fi·•1·'.1',"1:•:~·•:l/ •-•i•~
' ,·.: _ •'( ··,., ' ' '• . l,t'.!!'\'/,,,&, :,·-:. .-. · ..

'' \ •'
·/::•>. ·'· .r :
..•.
.·.-. / 1:·:; -.:,_.,_'.·~·· .-. " -,;'.

J ..• .';' ;i;Jttiti,*:ii;;.;; ' C•r,1;;£ •~;: !:,1/;:

·:uw.~·-:i:Ufreb:Y, •·,J:t,A e ··r:::af -tl't/:s··.fr~v~~:·iibi,,.~:a-s:~Hg·ne'ci" ·trti ab.oy_e_:··ur:e . - -·
O,; , i'.:]~; . '\::~ti~~: ''" .. _
. . . :.- t?.oCJ,~Y.-·i®,~...... . .,. ,.,;,..•.•. ,.-....................,..·t ,•,,q ,.i·,:~,.•~,,....,~,11:,::,,,1f, :.:'.,: :: -?:.-..~-,{··•/~~. ','1,,.-.-,.-

j ,' ,'tf
::·~~:: :·~~;t;tJt~;-:i;~ri~.:~~~~l~itJ)tt:ti~ttf:f~f[:t .
.as . on -d~te---t>y ..-(f\~~:L'lfo .1·n$_ ~-r:ifq.c~:-9_otp.i:fr.~ifqii,.:·o( lo:dJ~.: ~f ]m:~l/ ~i\~~f.~(,_. ~::_· .-.'.
e.:a:!Do'v.:e .- P·ot icy- _.:w~:otl·-~u-e/ o.o°tfG,e·,,J,i.,-,\1ladi~~lito:& ::t•1a·r.t~~tr\:~-----,:.~-~---·
• ', t ~ , • ••;,, ;?, ' , , , • ,., ,; • . • ', • .;.- , .,. t

w:h.o;.tss\Le:d:· th~
' ' • 1 .,__ _ ' • , • - t ' • ~ ft ; ~•• l • .. . • ' '• ' , , _,) • - ,, - ...

. .--: . . -;·· :. : .·. . :: .: . _:-,. ··.. . .._

: . ••', .• ' ;_ ,.: ;,:: ;.,,.;-:;::~,i/.t ..t ;~;·--·,, :\ .: :;.~·-_:. ,<· . ·' ,,•..,;>, ,:,.},1::_
',;:_ ::; .'',.. ,, -~-- .
d'ercJace lh'at · I/Y/1,· .:-t i~'Me-.n:.o.t-' -.--!rieti~ ,:o.n~:,:a:n~·;0 ttT:~;~•:o:f.~t,~ · . -,.,
. .·~~~~~!l~Y:"..i .· · •· ~i;:~s·t~J-·NJfe:."al~t;,j·:1r'
.i'!\#::1gr1~~?X it::::;t 1
·

.·•·: :l~;i~~~:r -~~;ff(~::~;::fi! 1{!,h~ti:}'.!«it~'r?e!r:!~::~r··.·

:rie~iisfg:fthtei1:t~r0fr 8U.c.t.1nl1~s:a .; . ~- _ . . ,,._.. ,-:_~- ,. ,--
1
:'
-Survival Benefit. ·· ·. ·: .:
.. ' -·~

$ign'ature
.
,o( As's-
~-ra:d,::.

r
.. . .. ... . .

r tt· ~;: i~f'····'.'fr•·"<r·• ·'·•:-

I f" •• • o I • ~ . •

. ·.Si £1 n.11t Of Ass i!J r-i.ia \ ,··. ·,. ,,.;,':·· ·l ••f/: ;., ,;;2 .,
·...N~rne .pf .~$..~.Y r:e d :: ·/~. ~.: ~,. ..: ;_: .•,·;... ;.·~<·.~•;.,:.•_- t~ ..)fo ;;.~·;._ •\• :.;,:·, .: ~.:;_~,;~~_
:,~,::,:i.:-.. .'.; ••
. .... f ' .;_ -v. ·:_(iN.·.~t~:;-ciK t~fTE:R·:s).'. -··. ·· :· · .' . . 1
. --
I • t •••, ;, · ' • :.. ' ' \ : • •••• ,, t ,:; '. :. . -•• • .•• •_I ..., •
·•· ,.- ,.

.' :Ad;q f-~ S:S.-·-':-; • ,,, •(·• ; .-~ ...:,;. ·<· -~~-.) ·:,.; :: . .,. ;_: ;_.-; ~. .-~-~~~~{\~·~/f~:.:;:~_;{~\~·:' •.·i; .'.l: ::. ;' .. ·,-:. ;,•. •••-. (~;, ;: ~·..
. ,_•: •·.
.; '. ']: · .:,-:, .

,.,, ..
,·t••~ ':I;"•.' ~·/• ..•,•,.:•,:~_-,~••~ .:.::•;/~_~,;,.,•,,-, \ .;
' .. .
f : .• •: .•.,•,,I•.• ·.. .-.~·~'-:•• ;.-~
,• ·,_
:. -." :i" ... ..: ,-~·-·..~.
~-~--- :~:.i~ ..~.·

"! ....
,.
I. . -~
.i' .
·, ..

·· , L
l

' .
i