SELF DECLARATION

DHARWAD DISTRICT
(MTA-LOCALISED CLAIMS SURVEY, 2021)

I, _____________________________________________________________, Age.
______Yrs, R/o. _____________________________________________________________
__________________________________________________________________ hereby
declare that I have been selected to conduct _____________ Survey with Krishi
Care Management Services for ____________ Insurance Company in the
__________ District of ____________ State.

During my course of Work I will not indulge in any kind of illegal, unethical practices in
the work assigned to me. I will not take any cash or kind from any farmer, his
representative or whomsoever concerned in the course of work. I will perform my
duties as assigned and directed by my superiors from time to time. Failing which I shall
be liable to be penalized and the entire Survey payment shall be forfeited by the
company and necessary Legal Actions shall be initiated under various provisions of
Indian Penal Code, 1860 and Prevention of Money Laundering Act, 2002 and other
relevant laws.

I hereby authorize to deduct my payment for any mistakes / fraud / wrongful entries etc
conducted knowingly or unknowingly during the course of work. I shall pay necessary
damages caused due to my negligence. I authorize to deduct necessary TDS / Other
Deductions wherever applicable.

I hereby declare that I shall perform my work with due care and diligence. I shall take all
necessary steps to travel safely and follow Covid-19 Protocols in force. In case of any
mishaps I shall be held myself responsible.

Signature of the Staff:

Left Hand Thumb Impression:

Name of the Staff:

KCID:

Mobile Number:

Email ID:

Reference Name and Mobile Number:

Emergency Contact Person &

Number:
Blood Group:

Date: ____________________ Place: __________________

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RECEIVED ON: ____________________ RECEIVED BY: _____________________