INDEMNITY BOND FOR PAYOUT WITHOUT ORIGINAL POLICY
DOCUMENT
(To be stamped Rs. 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 all Payees & Surety)
_____________________________________________________________________________________
_____________________________________________________________________________________
(Residential address of Payee/s)
____________________________________________________________ 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)
and whereas the said Company SBI LIFE has on the said________________________________________
_____________________________________________________________________________________
(Names of all Payees & Surety)
undertaking to enter into the said Company a covenant of the nature hereinafter appearing agreed to
pay to the said ________________________________________________________________________
(Name or Names of Payee/s)
_______________________________________________________________ the value of the said Policy
viz. Rs. ________________________ now know ye and these presents witness that in pursuance of the
said agreement and in consideration of the said Company having agreed to pay the value of the said
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Policy to the said_______________________________________________________________________
(Name or Names of Payee/s)
(The receipt whereof is hereby acknowledged) they the said____________________________________
(Name or Names of Payee/s & Surety)
_____________________________________________________________________________________
_____________________________________________________________________________________
their heirs, executors or administrators will from time to time and at all times save and keep harmless
and indemnified the said Company SBI LIFE its successors and assignees of and from all actions, suits,
costs claims and demands of whatever nature and kinds over which may be instituted, preferred
claimed or made against the said Corporation, its successor or assignees by any persons or person by
reason of his, her, their possession of or right to the said original
_____________ _______________________________________________________________________
[Pol. No. or Assignment Deed Dated]
by reason of anything in relation to the premises.
In witness whereof the said_______________________________________________________________
(Names of Payee/s & Surety)
have hereunto put their hands at _____________this _______________day of _______________20____
Signed and delivered by the said __________________________________________________________
(Names of Payee/s & Surety)
_____________________________________________________________________________________
In the presence of:
W 1)Full Signature of Witness: _________________________ 1)__________________________
(Policy holder’s Signature)
I Name of Witness 1:________________________________
T 2)__________________________
Designation:____________________________________ (Assignee’ Signature)
N
E Address: _______________________________________
S 2)Full Signature of Witness: _________________________ Signature of Surety:____________
S
Name of Witness 2:________________________________ Name of Surety:_______________
E
S Designation:____________________________________ Address: _____________________
Address: _______________________________________
N o t e: If this Bond is signed in Vernacular one of the attesting witnesses should be requested to certify
that the contents of this Bond were explained to the party in vernacular before execution. Illiterate
Persons must affix their thumb impression which should be attested by Magistrate S.E.M. A Gazetted
officer, a Block Development Officer or Class 1 Officer of the Corporation Provided He is fully satisfied
about the identity of the claimant
1800 267 9090
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