(To be notarized on a Non-Iudiclal Stamp Paper of 100/-) AFFIDAVIT | __, son/daughter/wife, of aged about years, Indian tnhabitant, presently residing at do hereby solemnly state, declare and affirm as under: 1, That had submitted a Proposal for obtaining a life insurance Policy from Kotak Mahindra Life Insurance Company Ltd. 2. That subsequent to submission of the aforementioned Proposal, the Company issued Policy No. (the “said Policy"/ “Policy Contract”). The Policy Contract for the said Policy wasissued tome. 3. Thatthe said Policy has been lost/ misplaced andis not available withme. 4, That at my request and based on the aforesaid representation, the Company has agreed to issue a duplicate Policy Contract in lieu of the misplaced/lost Policy Contract. 5. That the original or duplicate Policy Contract shall not be misused. lalso confirm that in the event of the said Original Policy Contract is being recovered or found, | shall forthwith return the same to the Company, Failure to return the same shall amount to breach of contract and | shall be accountable and liable for any misuse of the same. 6. That the above statements and declarations are true and correct and | have not concealed any material or relevantinformation in this regard. 7. That any stamp duty payable on this Affidavit shall be borne by me. Solemnly affirmed as aforesaid at This__day of, 20. Deponent Kotak Mahindra Life Insurance Company Ltd. 'ROAL Regn No. 107, CHV UGEO3OMH2000RLC128503, Regd Office: Bth Floor, Plot #C- 12, G Block, BKC, Bandra), Mumba! 400.051 For any comrespondence kindly contac us at 901 (A-Wing) &$02(B-Wing), Sth Floor, ntelion Square Bulding No 4), infty Park, (Off WE Highay, Geoeral AK Vaidya Marg, Malad (2, Mumbai - 400 057. (69122) 6725 6166 0} 6742 5650) 1800 209 8800 (to tee) vu kotalf com | Wie to Hv WECARE/ WhatsApp: 9321003007 [CCAPS\CF! Duplicate pol- affidavit formooa © scanned with OKEN Scanner