F. No.
3815 R
Life Insurance Corporation of India
ROHTAK DIVISION
(To be stamped Rs. ___________________ At the stampoffice or Collector's Office BEFORE EXECUTION or to becopied out on a non-
Judicial stamped Paper of equal value.
To all to whom these present shall come _________________________________________________________
________________________________________________________________________________________ of
(Name of all Payees & Surety)
__________________________________________________________________________________________
(Name of all residence of Payee/s)
___________________________________________________________________ inhabitiants send Greetings
where a Policy of Insurance Numbered _________________________ for Rs.___________________________
was granted on__________________________________ by the Life Insurance Corporation of India,
established by the Life Insurance Corporation Act 31 of 1956 (hereinafter referred to as the Corporation) on
the life of__________________________________________________________________________________
(Name of Policyholder)
and WHAREAS ___________________________________________________________________ which was in
(Policy No. or Assignment Deed Dated)
Possession of _________________________________________________________ has been lost or misplaced
(Name of Policyholder)
and whareas the said Corporation has on the said _________________________________________________
__________________________________________________________________________________________
(Name of all Payees & Surety)
undertaking to enter into with the said Corporation a Covenant of the nature herein after appearing agreed to
pay to the said ______________________________________________________________________________
(Names or Name of Payee)
__________________________ the value of the said Policy viz. Rs. ___________________________________
___________________now know you and there presents witness that in pursuance, of said agreement and in
consideration of the said Corporation having agreed to pay the value of said policy _______________________
(Name of Names of Payee)
_____________________________________________ (the receipt whereof is here by acknowledged they the
said ______________________________________________________________________________________
(Names of payee-s and surety)
__________________________________________________________________________________________
do here by for themselves, their heirs, executors or administrators Covenant with the Corporation, its
successors and assigns, that they the said ________________________________________________________
(Name of payee-s and surery)
__________________________________________________________________________________________
their heirs, executors of administrators will from time to time and at all times and at all times save and keep
harmless and in dermnifed the said Corporation, its successors and assigns: of and from all actions, suits, cost,
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 assign by any person or persons by reason of his her or their
possession of or right to the said original ___________________________________________ by reason of
(Policy No. or Assignment deed date)
anything in relation to the premises.
In witness of the said ________________________________________________________________________
(Names of Payre-a and Surety)
have there upto put their hands at _______________________ this _____________________ day of 20______
Signed and delivered by the said _______________________________________________________________
(Names of Payee-s & Surety)
__________________________________________________________________________________________
in the presence of:
__________________________
(Signature)
WITNESSES
Full Signature
of witness _____________________________
__________________________
Designation ___________________________ (Signature)
Address ______________________________
Full Signature Signature
of witness _____________________________ of surety _____________________________
Designation ___________________________ Designation ___________________________
Address ______________________________ Address ______________________________
Note: If this Bond is in Vernacular one of the attesting witness should be requested to certify that the contents
of this Bound were explained to the party in vernacular before execution.
