Form Of Application For Special Policy In Lieu Of The Lost Policy
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FORM OF APPLICATION FOR
SPECIAL POLICY
In lieu of the Lost Policy
Dear Sir,
Re: REQUEST FOR ISSUING A SPECIAL POLICY IN LIEU OF THE LOST POLICY
I give herein below the details of my policy:
Policy Number
Name of the Assured
Name of Proposer*
Postal Address
Phone Number
Residential Address
*where the life assured is not the policy owner.
I want a special policy document to be issued since the Original Policy document is not available for the
following reason :( PLEASE TICK ANYONE ONLY)
I declare that I have lost (or) accidentally destroyed (rendering it illegible) the above policy
document (If available, remnants may to be enclosed).
I declare that I have not received the Policy document either through Post or delivery and that it is
also not with my Solicitor, Bank or any other personal representative.
Any other reason:
………………………………………………………………………………………
………………………………………………………………………………………
I DECLARE THAT
I have NOT assigned or transferred this policy document to any person/ persons/ company/
•
financial institution for any reason whatsoever.
I fully understand that the issue of duplicate policy document will render the original policy
•
document NULL and VOID.
I will indemnify LICI and its executors, successors, assigns against all claims, suits, liabilities,
•
demands or actions that may be instituted, preferred, claimed or made in relation to this policy.
I make these declarations solemnly by virtue of the Statutory Declaration Ordinance 1970 conscientiously
believing them to be true in every particular.
__________________________________________
Date:
Place:
Signature of the Life Assured/Assignee/Proposer*
The declaration and signature of the Life Assured/Assignee/ Proposer (if applicable) should be witnessed
by a Magistrate/Commissioner for Oaths/Justice of Peace.
Name & Address of the Witness
…………………………….
_________________
……………………………..
(Signature of Witness)
……………………………..
SEAL:
………………………………
NOTE: Please check all the details and return/mail the completed form, along with the requisite fees to your servicing
office at: LICI, GPO 266, No. 11 Butt Street, Suva (or) LICI, PO Box 789, No.5 Tui Street, Lautoka.
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