Vanguard Life - Indemnity Form

INDEMNITY REQUEST

Customer Acknowledgement (Indemnity for not presenting Policy Document)
Name of Policyholder:*

First NameLast Name
Policy Number:*
Branch:
Name of Claimant:
Email*
example@example.com
Address
Mobile Number
Please enter a valid phone number.
Email
example@example.com
Policy Type
Sum Assured
Claim Type
Claim amount
1. I, blanks of above address, am the policyholder/claimant under the above-mentioned insurance policy issued by Vanguard Life Assurance Company Limited (hereinafter referred to as the Company) requesting for the above stated claim but could not provide the original policy document.
Reasons
File Upload

Cancelof
2. I agree that, should I received the claim amount from Vanguard Life Assurance, by this the Company has discharged its full and final obligations under the contract. The Original Policy Document if found later shall be returned/delivered to the company and will not be considered for payment of benefits. Consequently, my beneficiaries, assignees, and personal representatives are not entitled to any benefits under this policy.
Signature of Policyholder (Claimant)

Clear
Date

MonthDayYear
Date
Should be Empty:

INDEMNITY REQUEST