MEDICAL INSURANCE UNDERTAKING

I, undersigned, ________________ hereby declare that,

1. I am an insured person who is a policyholder of __________________ Insurance Company Limited. Therefore, I give approval to the employer to not take an insurance policy in my name as required by law under the Employee's Compensation Act, 1923.
2. I hereby agree to submit a copy of my insurance policy for the verification and documentation of the company.
3. I signify my willingness to submit to the company a copy of the renewed policy, as and when it is renewed.
4. The company shall not be responsible for the renewal of the insurance policy or for the payment of premium.

I hereby state that all the information and documents that will be provided by me pursuant to this undertaking shall be true and correct to the best of my knowledge.

Name of the employee:

Signature:

Date: