DECLARATION I,………………………………………………………………………… (Name), ………………..................... ........................................................................................................................................................ ........................ ........................................................................................ (Official/Residential Address) hereby solemnly affirm and declare that the original State Life Insurance Policy ……………………………….. (Policy No) issued in favour of me / Shri/Smt.……………………………………………………............... said to have forwarded by the Director of Insurance, Kerala State / District Insurance Officer, ................................................................................ is irrecoverably lost/damaged/not received. I have made sincere attempt to search the original Policy, but turned futile. I undertake to surrender the original Policy as and when received or recovered. Signed on the ………… day of ………………………......., 20..........
I undertake to surrender the original Policy as and when received or recovered. Signed on the â¦â¦â¦â¦ day of â¦â¦â¦â¦â¦â¦â¦â¦â¦......., 20.......... Signature : .
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Voluntary Hospital Indemnity Coverage: The exclusion regarding work-related injury or sickness only applies to the extent you are covered or. are required to be covered by Workers' Compensation law. Page 3 of 12. 3 -1 Vol Hospital indemnity Plan Desc
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