Form 3807

Letter to be completed and signed by the Surety

The General Manager,
LIC (International) B.S.C(C)

Dear Sir,
I wish to inform you that I am prepared to execute an Indemnity Bond in favor of the LIFE INSURANCE
CORPORATION INTERNATIONAL B.S.C(C) to enable it to pay to
Mr./Ms ………………………………………………………………………………………………………………..
(Name and Address of Claimant)
………………………………………………………………………………………………………………………..
Under its Policy No…………………………………….. without insisting on legal evidence of title/production of Policy
certificate.

Consequently I have filled in the questionnaire form given below:

QUESTIONS ANSWERS

1. Your full Name

2. Your Permanent Address

3. Your Age

4. Your father’s Name

5. Are you related to the Policy Holder? If so state

the relationship

6. What is your present occupation and present address?

7. What is your present occupation and income and what

are the other sources ?

8. What property movable or immovable you possess and

what is the present value?

9. Is the property free from encumbrance?

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I do hereby solemnly assure the Corporation that I have thoroughly understood and correctly answered the above questions.

Declared at …………………………………………….. this………………….. day of ………………….20……..

WITNESS
……..……………………………………..
Signature : Signature of Surety

Name :

Address :

NB: N.B.: This application must be countersigned by a Clergyman a Gazetted Officer, a President of the Local Board, a
Chief Executive Officer of a Municipality, a Justice of the Peace, a Magistrate, a Commissioner of Oaths, a Notary
Public, Collector, a Judge, a Headmaster of a High School, an Advocate, a President of a Village Panchayath, or an
Officer or a Development Officer (who is conformed and has served for at least five years as a Development officer) of
the Corporation provided he knows the applicant.