DECLARATION CUM UNDERTAKING

This Declaration cum Undertaking made and eecuted at !!!!!!!!!!!!!!!on

this !!!!!!! da" o# !!!!!!!!!!!!!!!!!!!!$%%& '"
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!son o# !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!
and residing at
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do here'" solemnl" ackno(ledge) a*rm) state and undertake as #ollo(s+
,- That in terms o# the .olic" o# ICICI /enture 0unds Management
Com.an" Limited 1the 2Com.an"34) (hich I ha5e read 1hereina#ter the
26olic"34 I am eligi'le #or
!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!1Insert details o# the Mediclaim
6olic"4 to 'e .rocured and .ro5ided '" the Com.an" to me at the cost o#
the Com.an" and
that the Com.an" has .rocured !!!!!!!!!!!!!!!!!!!!!!!!6olic" 1hereina#ter
re#erred to as the 2Mediclaim 6olic"34 and this Mediclaim 6olic" is also
etended to m" de.endants namel"
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1hereina#ter collecti5el" re#erred to as the 2De.endants34
$- In consideration o# the Com.an" ha5ing .rocured the said Medi7
claim 6olic") I) !!!!!!!!!!!!!!!!!!!!here'" unconditionall") a'solutel" and
irre5oca'l" undertake and agree to the Com.an" that m" de.endant8s+
is8are not gain#ull" em.lo"ed '" an" other com.an"9 and #
(orking) the de.endant8s is8are not co5ered '" his8her8their
em.lo"er under an" other mediclaim .olic" o:ered '" the
em.lo"er-
is8are ;nanciall"7de.endent on the em.lo"ee-
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I undertake on 'ehal# o# m"sel# and m" de.endant8s to a'ide '" and adhere
to the terms and conditions o# the Mediclaim 6olic" and .ro5isions o#
the a..lica'le la(s-
,
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I shall a'ide '" all the .ro5isions o# the 6olic" and an" amendments thereto
o# the Com.an") #rom time to time) in res.ect o# .ro5iding Mediclaim
6olic" to em.lo"ees- In the e5ent o# (ithdra(al o# the scheme) I shall
a'ide '" the decision o# the Com.an"-
>- In the e5ent o# an" 'reach or de#ault o# this Undertaking '" me) the
Com.an" shall 'e entitled to reco5er all and an" amounts due #rom
me .ursuant to this Undertaking #rom m" salar" and retirement
'ene;ts .a"a'le to me '" the Com.an" and I authori?e the Com.an"
to make such deductions in its sole discretion
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@- I unconditionall" and irre5oca'l" agree that the this Declaration cum
Undertaking and Indemnit" shall 'e go5erned '" and construed in
accordance (ith the a..lica'le Indian la(s and the courts situated in
Aangalore) Karnataka shall ha5e eclusi5e Burisdiction in the e5ent o#
an" dis.ute in this regard-
Date+ Cignature !!!!!!!!!!!!!!!!!!!!
6lace+ Name !!!!!!!!!!!!!!!!!
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