Date: ___________, 2019

To,

Medi Assist Insurance TPA Private Limited

Tower D, 4th Floor, IBC Knowledge Park,
4/1 Bannerghatta Road, Bangalore
Pin: 560 029

Subject: Compliance with IRDAI Regulations

Ref.: IRDAI circular No. IRDAI/HLT/GDL/CIR/114/07/2018 dated 27-Jul-2018

IRDAI Circular No. IRDAI/HLT/GDL/CIR/122/07/2019 dated 26-July 2019

UNDERTAKING

We, _____________________ do hereby declare that in compliance with IRDAI circular No.
IRDAI/HLT/GDL/CIR/114/07/2018 dated 27-Jul-2018 and IRDAI Circular No.
IRDAI/HLT/GDL/CIR/122/07/2019 dated 26-July 2019:

(i) We have registered our organisation with Registry of Hospitals in the Network of Insurers
(ROHINI) maintained by Insurance Information Bureau (IIB)

(ii) We shall obtain: (Please tick on correct option)

(a) Pre-entry level Certificate (or higher level of certificate) issued by National Accreditation
Board for Hospitals and Healthcare Providers (NABH)

or

(b) State Level Certificate (or higher level of certificate) under National Quality Assurance
Standards (NQAS), issued by National Health Systems Resources Centre (NHSRC) within
one year of empanelment of our organisation with Medi Assist Insurance TPA Private Limited

For and on behalf of __________________

___________________________
Name:
Designation: