PORTUGUESE FRATERNAL SOCIETY OF AMERICA
Duplicate Surrender Death
PORTUGUESE FRATERNAL SOCIETY OF AMERICA 1120 East 14th Street, San Leandro, CA 94577-4585 Phone: (510) 483 – 7676 ~ (866) 687 – 7372 ~ Fax (510) 483 - 5015
AFFIDAVIT AND AGREEMENT PERTAINING TO LOSS OR DESTRUCTION OF POLICY , being duly sworn, depose and say that I am the
I, Insured
Annuitant
Beneficiary
Owner of policy No.
That said Policy has been lost or destroyed and that I have no knowledge as to its whereabouts, that no person or persons, corporation or association, has any claim or interest in said Policy, by virtue of any sale, assignment or pledge thereof, except as follows: That the circumstances of the loss or destruction of said Policy were as follows: That the Beneficiary or Beneficiaries on the lost Policy is (are):
AGREEMENT On the basis of the above affidavit, I hereby request that the Supreme Council of PFSA issue a copy of the Lost Policy described above to evidence the contract witnessed hereby. In consideration of the granting of this request, I undertake and agree as follows: That said copy shall stand in the place and stead of the original Policy for all purposes, and that the original Policy, if still in existence shall be of no future force, and as evidence of the insurance contract of which it bore witness. That the original Policy, if it later comes into my possession, shall be returned promptly to the insurer. That I will consider the insurer harmless from all loss or injury which may occur as a direct or indirect result of its act of issuing said copy.
Signature
(X)
Phone #
Form Must be Witnessed by a Notary Public (Notarization is available at the PFSA Main Office) State of California County of
)
On
before me, (insert name and title of the officer)
personally appeared , who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal.
Signature
(Seal) To be Completed by PFSA Office Staff
Date Received: Council No.
Duplicate Issued: Member No.
Lost Policy Form 01.01.2010
PORTUGUESE FRATERNAL SOCIETY OF AMERICA 1120 East 14th Street, San Leandro, CA 94577-4585 Phone: (510) 483 – 7676 ~ (866) 687 – 7372 ~ Fax (510) 483 - 5015
AFFIDAVIT AND AGREEMENT PERTAINING TO LOSS OR DESTRUCTION OF POLICY , being duly sworn, depose and say that I am the
I, Insured
Annuitant
Beneficiary
Owner of policy No.
That said Policy has been lost or destroyed and that I have no knowledge as to its whereabouts, that no person or persons, corporation or association, has any claim or interest in said Policy, by virtue of any sale, assignment or pledge thereof, except as follows: That the circumstances of the loss or destruction of said Policy were as follows: That the Beneficiary or Beneficiaries on the lost Policy is (are):
AGREEMENT On the basis of the above affidavit, I hereby request that the Supreme Council of PFSA issue a copy of the Lost Policy described above to evidence the contract witnessed hereby. In consideration of the granting of this request, I undertake and agree as follows: That said copy shall stand in the place and stead of the original Policy for all purposes, and that the original Policy, if still in existence shall be of no future force, and as evidence of the insurance contract of which it bore witness. That the original Policy, if it later comes into my possession, shall be returned promptly to the insurer. That I will consider the insurer harmless from all loss or injury which may occur as a direct or indirect result of its act of issuing said copy.
Signature
(X)
Phone #
Form Must be Witnessed by a Notary Public (Notarization is available at the PFSA Main Office) State of California County of
)
On
before me, (insert name and title of the officer)
personally appeared , who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of California that the foregoing paragraph is true and correct. WITNESS my hand and official seal.
Signature
(Seal) To be Completed by PFSA Office Staff
Date Received: Council No.
Duplicate Issued: Member No.
Lost Policy Form 01.01.2010
