*

R *
(Mandatory)

*
(Mandatory)
Self Declaration :

I hereby wish to inform that the information provided about my hospital towards
empanelment with Star Health Insurance are true to my knowledge. I shall definitely
abide by the terms and conditions of Star Health and permit Star Health Officials to
visit my centre for inspection of Infrastructure facilities from time to time. I, solemnly
confirm that we have not approached any intermediary or paid in any kind to anyone
connected / not connected with Star Health Insurance towards empanelment of our
hospital. In the event of any evidence on such approach for empanelment, I am aware
that I shall be liable for appropriate disciplinary measures by Star Health Insurance
including termination of the contract.

For Hospital

Name of Signing Authority with Designation :

Signature with date :

Seal Stamp :

Note :

Please provide signature & affix hospital stamp on all the pages.

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