AFFIDAVIT CUM INDEMNITY (For Claim purposes)

I, ANTHONY BIMAL ROZARIO, son of WILLAMO ROZARIO, aged about

55years, Indian Inhabitant, residing at RISHI BANKIM NAGAR,
BARUIPUR, SOUTH 24 PARGANAS,WEST BENGAL – 700 144 do hereby
solemnly state, declare and affirm as under:
i. I say and declare that, Mr ANTHONY BIMAL ROZARIO (the
“deceased policyholder”) was and is the bonafide policyholder of the
subject policy.
ii. I say and declare that on 10/08/2020, the said deceased
policyholder made the proposal for the KOTAK SMART LIFE from
Kotak Mahindra Life Insurance Company Limited having its Head
Office at Kotak Infinity 8th Floor Zone II, Building No. 21, Kotak Infinity
Park, Off Western Express Highway, General AK Vaidya Marg, Malad
(East), Mumbai 400 097 (“Kotak Life Insurance”) under a proposal
application form bearing policy number 74367292.
 (2)

iii. I say and declare that subsequent to the aforementioned Application, Kotak
Life Insurance issued the policy contract bearing number 74367292 (the “said
Policy / said Original Policy contract”) was issued and dispatched to the deceased
policyholder.
iv. I say, declare and confirm that I am the nominee appointed under the said
Policy and hence acquired the right to make the claim before Kotak Life
Insurance on behalf of the policyholder.
v. I hereby say, declare and confirm that, the said Original Policy contract have
lost / misplaced which was issued to the said deceased policyholder and is no
longer available with me.
vi. I say that I have tried to locate the same to the best of my efforts and am
unable to do so and have despaired of locating the same. .
vii. I say and confirm that at my request and based on the aforesaid
representation, Kotak Life Insurance have agreed to waive the condition of
submitting the said Original Policy contract against furnishing this Affidavit-cum-
Indemnity.
viii. I say and declare that in the event said Original Policy contract is located, I
agree to forthwith return the said Original Policy contract to Kotak Life Insurance
immediately without any delay.
ix. In consideration of non-submission of the Original Policy contract, I hereby
indemnify and undertake to continue to hold Kotak Life Insurance indemnified
and harmless from and against any payment that may be made and/or any loss,
damage or costs (including any legal fees) that may suffered and/or incurred by
Kotak Life Insurance towards in respect of the Original Policy contract.
x. 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.
 (3)

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

Solemnly affirmed as aforesaid at ______

This ____ day of _____, 20____

Deponent

BEFORE ME