Form No.

3815

Life Insurance Corporation of India

(To be stamped Rs. …………………………………… at the Stamp Office or Collector’s Office before execution or to be copied out
on a non-judicial Stamped Paper of equal value)

To all to whom these presents shall come …………………………………………………………………………………...

……………………………………………………………………………………………………………………………………..
(Name of All payees & Surety)

………………………………………………… inhabitants send Greeting whereas a Policy of …………………………...

…………………………………………………………………………………………………………………………………….
(Place of residence of payee/s)

Insurance Numbered ……………………………… for Rs. ……………………………… was granted on

………………………………………. by the Life Insurance Corporation of India, established by the Life Insurance
Corporation Act of 1956 (hereinafter referred to as the Corporation, on the life of ……………………………………...
…………………………………………………. and WHEREAS …………………………………………….............. (Name of
Policy holder)

………………………………………………………………………………………… which was in (Policy No. and

Assignment Deed dated)

the possession of …………………………………………………………………………………………………… has been

(Name of policy holder )

lost or misplaced. And whereas the said Corporation has on the said …………………………………………………….

…………………………………………………………………………………………………………………………………
(Name of payees & Surety)

undertaking to enter with the said Corporation a Covenant of the nature hereinafter appearing agreed to pay the said
………………………………………………………………..............................……………………………………........
……………………………………………………………… (Name or Names of Payee)

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 Corporation having agreed
to pay the value of the said Policy …………………………………………………………………………………….

……………………………………………………………………………………………………………………………………...
(Name or Names of Payee/s)

(the receipt whereof is hereby acknowledged) they the said ……………………………………………………………….

……………………………………………………………………………………… (Names of payee/s and Surety)

do hereby for themselves their heirs, executors or administrators Covenant with the said Corporation, its successors
and assign, that they the said …………………………………………..........................................................

……………………………………………………………………………………………… (Name of Payee/s and surety)

1
their heirs, executors or administrators 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 king 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 heirs possession of or right to the said original
…………………………………………………………………………………………………… by reason of anything in
…………………………………………………………………………………….................................

(Policy No. or Assignment deed dated)

……………………………… relation to the premises.

In witness where of the said ……………………………………………………………………………………………………

…………………………………………………………… (Names of Payee/s and Surety)

have there unto put their hands at ……………… this …………………. day of ….………………. 2013

Signed and delivered by the said …………………………………………………………………………………………….

……………………………………………………………………… (Name of Payee/s & Surety)

In the presence of : ……………………………………………..

(Signature)

Full signature :

of witness ……………………………….. ……………………………

(Signature)

Designation ……………………………...

Address ………………………………….. Signature

Of Surety ……………………………

…………………………………………….. Designation ………...………………

Address ……………………………..

Full signature : ……………………………………….

of witness ………………………………….

Designation …………………………………

Address ……………………………………..

……………………………………………….

Note : If this 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.