AFFIDAVIT CUM INDEMNITY( For Claim purposes – One Legal Heir ) ( On a Non – judical Stamp paper worth Rs. 200/- and to be Notarized )

  AFFIDAVIT CUM INDEMNITY( For Claim purposes – One Legal Heir )  ( On a Non – judical Stamp paper worth Rs. 200- and to be Notarized )

Example :- Yogesh Kumar

AFFIDAVIT CUM INDEMNITY

( For Claim purposes – One Legal Heir )

( On a Non – judical Stamp paper worth Rs. 200/- and to be Notarized )

I, YOGESH KUMAR son of  JAGDISH PRASAD, aged about 30 Years, Indain Inhabitant, residing at _________________________________  do hereby solemnly state, declare and affirm as under :

i.                    I say and declare that, Mr/JAGDISH PRASAD  ( the “deceased policyholder”) was and is the bonafide policyholder of the subject policy.

ii.                  I say declare that on .................................................. , the said deceased policyholder made the proposal for the SILVER INVEST  ( Name of the plan ) form Bajaj Allianz Life Insurance Co Ltd. (“ the Company”) under a proposal application form bearing policy number ......................................

iii.                I say and declare that subsequent to the aforementioned Application, the Company issued and dispatched to the deceased policyholder.

iv.                I declare that thare is no Probated will in existence due to which I am not in a position to furnish the copy will,probated and/or otherwise and further as preferring of necessary proceedings before an appropriate Court for a Succession Certificate would take anywhere upto a minimum of about 2-3 years, Therefore, I request the Company to accept my submission herein made.

v.                  I say, declare and confirm that I am the only legal heir of the said deceased policyholder and hence, got the right to collect the insurance money lying before the Company and have therefore acquired the right to make the claim before the Company on behalf of said deceased policyholer.

vi.                I enclose herewith the documentary proofs pertain to the relationship and identity proof.

vii.              I say confirm that at my request and based on the aforesaid representation, the Company has agreed to pay the claim amount to me against furnishing this Affidavit-cum-Indemnity.

viii.            In consideration of above, I hereby indemnify and undertake to continue to hold the Company indemnified and harmless from and against any payment that may be made and/or any loss, damage or costs ( including and legal fees ) that may suffered and/or incurred by the Company towards in respect of the claim payment to me.

ix.                I say that the above submissions and declaration are true and no portion thereof is false and I have concealed nothing material or relevant to the matter.

x.                  Any stamp duty payable on this Affidavit cum Indemnity shall be the responsibility of and shall be born by the Deponent alone.

xi.                I am executing this Affidavit cum Indemnity out of my free will without any force or coercion.

Solemnly affirmed as aforsaid at___________

This 14 day of      /12/2017

Deponent

BEFORE ME ‘

NOTARY PUBLIC