Apne liye. Apno ke liye.

SBI Life Insurance Company Limited

INDEMNITY BOND FOR CLAIM PAYOUT WITHOUT ORIGINAL POLICY DOCUMENT

(To be stamped ` ___________ of the Stamp Office or Collectors BEFORE EXECUTION or be copied out on
non-Judicial Stamped paper of equal value.)

To all to whom these present shall come __________________________________________________

________________________________________________________________________________ of
(Names of Policy Holder or Claimants & Surety*)

_____________________________________________________________________________________

_____________________________________________________________________________________
(Residen address of Policy Holder or Claimants)

____________________________________________________________ Whereas a Policy of Insurance

Numbered___________________________ for Rs .____________________ was granted on

_________________ __________ by the SBI Life Insurance Company Limited, having its Central

Processing Centre at______________________ on the life of

____________________________________________________________________________
(Name of Policyholder)

and WHEREAS ______________________________________________________________ which was in

(Policy No. or Assignment Deed Dated)

Possession of ___________________________________________________ has been lost or misplaced

(Name of Policyholder or Claimant)

and whereas the said Company SBI LIFE has on the said________________________________________

_____________________________________________________________________________________
(Names of Policy Holder or Claimants & Surety*)

undertaking to enter into the said Company a covenant of the nature hereina er appearing agreed to
pay to the said ________________________________________________________________________
(Names of Policy Holder or Claimants)

_______________________________________________________________ the value of the said Policy

viz. Rs. ________________________ now know ye and these presents witness that in pursuance of the
said agreement and in considera of the said Company having agreed to pay the value of the said
Policy to the said_______________________________________________________________________
(Names of Policy Holder or Claimants & Surety*)

SBI Life Insurance Company Limited: Registered and Corporate Office: Natraj, M.V. Road & Western Express Highway Junction, Andheri(East), Mumbai- 400 069. Tel.: (022) 61910000.
Central Processing Center: 7th Level (D-Wing) & 8th Level, Seawoods Grand Central, Tower 2, Plot No. R-1, Sector-40, Seawoods, Nerul Node, Navi Mumbai- 400 706. Tel.: (022) 66456000.
IRDAI Registration No. 111. CIN: L99999MH2000PLC129113. Toll Free No. 1800 267 9090 (From 9.00am to 9.00pm). Visit: www.sbilife.co.in E-mail: info@sbilife.co.in

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 Apne liye. Apno ke liye.

SBI Life Insurance Company Limited

(The receipt whereof is hereby acknowledged) they the said __________________________________
_____________________________________________________________________________________
(Names of Policy Holder or Claimants & Surety*)

their heirs, executors or administrators will from e to and at all es save and keep harmless
and indemnified the said Company SBI LIFE its successors and assignees of and from all suits,
costs claims and demands of whatever nature and kinds over which may be ins ed, preferred
claimed or made against the said Company, its successor or assignees by any persons or person by
reason of his, her, their possession of or right to the said original
_____________ _______________________________________________________________________
[Policy No. or Assignment Deed Dated]

by reason of anything in rela on to the premises.

In witness whereof the said_______________________________________________________________

(Names of Policy Holder or Claimants & Surety*)

have hereunto put their hands at _____________this _______________day of _______________20____

Signed and delivered by the said __________________________________________________________

(Names of Policy Holder or Claimants & Surety*)
_____________________________________________________________________________________

In the Presence of:

1)Full Signature of Witness: __________________ Full Signature ________________ Recent stamp

size
Designa _______________________________ Name of Policyholder/Claimant Photograph of
Policyholder/
Address: __________________________________ __________________________ Claimant

_________________________________________

2)Full Signature of Witness: __________________ Full Signature ________________ Recent stamp

size
Designa _______________________________ Name of Surety* Photograph of
Surety *
Address: __________________________________ __________________________

_________________________________________

N o t e: If this Bond is signed in Vernacular one of the es witnesses should be requested to c y that the contents of this Bond
were explained to the party in vernacular before ex erate Persons must affix their thumb impression which should be
ested by Magistrate S.E.M. A Gaze ed officer, a Block Development Officer or Class 1 Officer of the Provided He is
fully about the iden of the claimant
* If the net claim amount exceeds ` 5 lacs, then the document should be executed jointly by the Policyholder/Claimant
and Surety

SBI Life Insurance Company Limited: Registered and Corporate Office: Natraj, M.V. Road & Western Express Highway Junction, Andheri(East), Mumbai- 400 069. Tel.: (022) 61910000.
Central Processing Center: 7th Level (D-Wing) & 8th Level, Seawoods Grand Central, Tower 2, Plot No. R-1, Sector-40, Seawoods, Nerul Node, Navi Mumbai- 400 706. Tel.: (022) 66456000.
IRDAI Registration No. 111. CIN: L99999MH2000PLC129113. Toll Free No. 1800 267 9090 (From 9.00am to 9.00pm). Visit: www.sbilife.co.in E-mail: info@sbilife.co.in

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