Lost Policy Release Form

A Lost Policy release form is used in a situation where the insurance policy document is lost or misplaced by the insurance policy holder. The form provides for relieving the insurance company from all liabilities arising in future on account of loss of the policy document. The form also has clause for cancellation of coverage for the insured person in future.

Sample Lost Policy release form

Name of the policy holder                                                 ____________________

Communication address of the policy holder                   ____________________

Contact number of the policy holder                               ____________________

Name of the insurance company                                     ____________________

Communication address of the insurance company       ____________________

Contact information of insurance company                   ____________________

Kind of insurance policy                                                ____________________

Insurance policy number                                                ____________________

Date of issue of insurance policy                                   ____________________

Nominee of insurance policy                                         ____________________

Relationship of nominee with policy holder                 ____________________

Reason for policy release (lost/misplaced/destroyed)    ____________________

Policy cancellation request by policy holder                ____________________

Declaration by policy holder for no future claims        ____________________

Mode of cancellation of policy

Full-term premium                                                        ____________________

Part-term premium                                                        ____________________

Prorate premium                                                            ____________________

Signature of the policy holder                                       ____________________

Date of lost policy release given                                   ____________________

Signature of witness 1 for cancellation                        ____________________

Signature of witness 2 for cancellation                        ____________________

____________________________________________________________________

FOR OFFICE USE ONLY

Acceptance by insurance company                                 ____________________

Signature of authorized official of insurance company ____________________

Date of cancellation of insurance policy                         ____________________

Final amount paid to insurance policy holder                 ____________________

Category: Release Forms