Form Of Application For Special Policy In Lieu Of The Lost Policy Page 2
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1
2FORM OF INDEMNITY LETTER FOR
SPECIAL POLICY
In lieu of the Lost Policy
(To be obtained from a person of sound financial standing who is not related to the policyholder. This is required to be
submitted along with the application form for special policy only where the Sum Assured is F$10,000 or above)
M/s Life Insurance Corporation of India,
Suva/Lautoka.
Dear Sir,
Re: Policy Number __________________ on the life of ___________________________________
Sum Assured ___________________
I, __________________________________________________________(Name in Block Letters), wish to inform you
that I am prepared to execute an indemnity Bond in favour of the Life Insurance Corporation of India in respect of the
above policy. Consequently, I have filled in the questionnaire form given below:
1.
What is your relationship
with the Life Assured?
2.
What is your present
occupation?
3.
What is your total annual
Source
Annual Income
income and its sources?
4.
Are you paying Income
Tax? If yes, please furnish
your TIN number.
5.
Please furnish your FNPF
Number, if applicable.
6.
What properties (movable
Property description
Current
Whether free from
and immovable) do you
Market Value
encumbrance?
possess?
7.
Have you always been
solvent?
I make these declarations, after fully understanding them and solemnly by virtue of Statutory Declaration Ordinance
1970 conscientiously believing them to be true in every particular.
Declared at __________________ on this __________________day of _______________ 20______
Signature of Witness: ____________________
___________________________
Full Name of witness: ___________________
Signature of the Surety
Title: ___________________________
Address: _______________________________
_______________________________
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