Witness Details:

(2 witnesses required. The witnesses have to be other than staff/agent of HDFC Standard Life Insurance

Customer Acknowledgement Copy (Indemnity for Loss of Policy Document)

Policy No: ____________________________________ Policyholder name: ______________________________________________________

Branch: Date: time: Branch Stamp

TO BE EXECUTED ON NON JUDICIAL STAMP PAPER AS APPLICABLE STATE WISEINDEMNITY (For loss of Policy document)HDFC STANDARD LIFE INSURANCE COMPANY LIMITED

PSRF521611011605

1. I/We, ____________________________________age ________years and at present residing at (address) _____________________________________________________________________________________________________________________________________________am the Policyholder(s) under Policy no. ______________ dated ____________(hereinafter referred to as �Original Policy Document�) issued by HDFC Standard Life Insurance Company Limited (hereinafter referred to as �the Company�).

2. I/We have lost the Original Policy Document issued by the Company on the life of (Name(s) of the Life Assured) ________________________.The Policy was effective from (Inception date) ____________ for a sum assured of `_______________. The Original Policy Document has been lost on/around (mention the date of loss) _______________.

3. I/We, having lost the Original Policy Document sent by the Company have requested the Company to issue a Duplicate Policy Document for our insurance Policy with the Company. I/We agree that the Duplicate Policy Document will cancel the Original Policy Document and the Original Policy Document if found later will not be considered for the payment of benefits. The benefits will be payable on production of the Duplicate Policy Document only once the duplicate Policy is issued.

4. I/We confirm that I/We have not assigned, pledged or in any way disposed of or dealt with the said Policy nor have I/We created any pledge or encumbrance on the said Policy.

Sr. Name Address Signature

1

2

Now therefore, in consideration of the Insurance Company creating a Duplicate Policy Document for Policy Number_________________

I/We do hereby jointly and severally covenant with the Company, its successors and administrators respectively, that I/We shall at all times save, defend, indemnify and hold harmless the Company, its successors and assigns and the Directors and Managers thereof and their respective heirs, executors and administrators and each of their estates and effects from and against all actions, causes, suits, proceedings, accounts, claims and demands whatsoever on account of misuse, fraud of any kind on the Original Policy Document lost by us and against all damages, costs, charges, expenses and sums of money incurred in respect thereof or and I/We, the Policyholder/s undertake on demand by the Company to return and deliver to the Company the Original Policy Document when found by us in future.

Date: ________________ Place: __________________

Date: ________________ Place: __________________

(2nd Policyholder in case of joint life)

HDFC Standard Life Insurance Company Limited. CIN:U99999MH2000PLC128245.In partnership with Standard Life Plc. IRDAI Registration No. 101.thRegd. Off: Lodha Excelus, 13 Floor, Apollo Mills Compound, N. M. Joshi Marg, Mahalaxmi, Mumbai - 400 011.

SIGN HERE

SIGN HERE

(Signature of the Policyholder)

(Signature of the Policyholder)

For queries or more information, call us on 1860-267-9999 (Local charges apply). DO NOT prefix any country code e.g. +91 or 00. Available Mon-Sat from 10 am to 7 pm | Email - service@hdfclife.com |NRIservice@hdfclife.com (For NRI customers only) | Visit -www.hdfclife.com