The Guardian
Insurance & Annuity
Company, Inc.
Variable Products Administration
P.O. Box 26210
Lehigh Valley, PA 18002-6210
1-800-221-3253
APPLICATION FOR DUPLICATE OF CONTRACT LOST OR DESTROYED
Contract No.:
Date of Issue:
Annuitant:
The above numbered contract has been lost or destroyed under the following circumstances:
It is hereby certified that the contract is not assigned or pledged, and that the contract is not subject to any
bankruptcy proceedings, attachments or other lien, except:
The Guardian Insurance & Annuity Company, Inc. (GIAC) is therefore requested to issue a duplicate contract bearing
the same number as the lost or destroyed contract and otherwise identical to it.
In consideration of the issue of such duplicate contract GIAC is hereby released by the undersigned from any and all
liability under the lost or destroyed contract, which shall be cancelled and of no further effect after the issue of the
duplicate contract.
Dated at:
GIAC 28 (5/01)
this
day of
,Yr.
(Signature of Witness)
(Signature of Contract Owner)
(Signature of Witness)
(Signature of Joint Owner, in any)
(Signature of Witness)
(Signature of Assignee, if any)