AFFIDAVIT OF LOSS AND INDEMNITY AGREEMENT
STATE OF )
COUNTY OF )
________________________________________________________, hereinafter called “Deponent” , being
duly sworn, deposes and says:
1. Deponent is of legal age, resides at ______________________________________________________
______________________________________, and is entitled to the possession and is the legal
beneficial owner of the following stock certificate:
North Coast Life Insurance Company Stock Certificate No. ____________ for ____________ shares of
common stock, issued in the name of ______________________________________________________.
2. The original stock certificate was acquired by Deponent on or about (date) ________________________
and was lost, stolen, seized or destroyed on or about (date) _____________________________, under
the following circumstances: (Please advise where the original was kept and who had access to it, when
and by whom the loss was discovered, when and where the original was last seen, and what measures
have been taken to recover the original.) ___________________________________________________
3. The original (was) (was not ) endorsed. If the stock certificate was endorsed, describe the exact manner
of its endorsement, including the name and address of the endorsee. If the endorsement was by separate
instrument (such as a stock power), please so state.
4. Deponent has made or has caused to be made, a diligent search for the original, and has been unable to
find or recover it. Deponent has not sold, assigned, pledged, transferred, deposited under any agreement,
or hypothecated the original or any interest therein or (except as may be stated in the foregoing
paragraph) signed any power of attorney or other authorization respecting same which is now
outstanding and in force, or otherwise disposed of same; and (except as stated above) no person, firm,
corporation, agency or government other than the Deponent has asserted any right, title, claim, equity
or interest in, to or respecting the said original or the proceeds thereof.
5. This Affidavit of Loss and Agreement of Indemnity is made for the purpose of inducing North Coast Life
Insurance Company to refuse to recognize any person other than deponent as the owner of the original
and Deponent requests North Coast Life Insurance Company to refuse to recognize any person other than
Deponent as the owner of the original and Deponent requests North Coast Life to refuse to make any
payment, transfer, registration, delivery or exchange called for by the original to any person other than
Deponent and to refuse to take any other action pursuant to the request or demand of any person other
than Deponent and to issue a new stock certificate in North Coast Life Insurance Company in lieu of the
Affidavit of Loss and Indemnity Agreement
6. If Deponent should find or recover the original, Deponent will immediately surrender the same to North
Coast Life for cancellation without requiring any consideration therefor.
7. Deponent agrees, in consideration of compliance with the foregoing request, to indemnify and hold
harmless North Coast Life and any person, firm or corporation now or hereafter acting as its transfer
agent or in any other capacity, and also any successors in any such capacities, from and against any and
all liability, loss damage and expense in connection with or arising out of compliance with the request
of Deponent herein set forth, and further agrees to furnish to the above-described persons without any
expense to them, a bond of indemnity in case this Affidavit of Loss should at any time for any reason
in the opinion of such persons not afford them sufficient protection.
Signed, sealed and delivered by Deponent this __________ day of _____________________, 20 _________.
Subscribed and sworn to before me this _________ day of ________________________, 20 ____________.
Notary Public in and for the State of ___________________
residing at ______________________________________.