Indemnity for Lost Certificate

The original certificate (s) of this title relating to the under-mentioned securities of the above named company has/have been lost or destroyed.

Neither the securities nor the certificate (s) of title thereto has/have been transferred, charged, lent or deposited or dealt with in any manner affecting the absolute title thereto and the person (s) named in the said certificate (s) is/are the person (s) entitled to be on the register in respect of such securities.

I/we request you to issue a duplicate certificate (s) of title for such securities and in consideration of your doing so, undertake (jointly and severally) to indemnity you and the company against all claims and demands (and any expenses thereof) which may be made against you or the company in consequence of your complying with this request and of the company permitting at any time hereafter of the said original certificate (s).

I/we undertake to deliver to the company for cancellation the said original certificate (s) should the same ever be recovered.

    To the Directors of

    Particulars of Certificate(s) Lost or Destroyed


    We _____ hereby join in the above indemnity and undertaking.