Medical Reimbursement Form

Name Emp Code Financial year Date of Claim

Raju.G.S 200702146321 2010-2011 24/01/11

1. Please attach the medical bill along with claim sheet and submit the same in a envelop. 2 Mention the nature of claims & Employee code on the top of the envelop 3.Refer the medical reimbursement policy and read the foot notes

Bill No
3773 1051 3643 2092 2156 2898 2837 2710 2501 2440 2368 3069 3058 2902 1483 139 222 364 816 491 1907 1880 1190 4010 1442 1685 1712 201112034876 5381 932

Date of Bill
21/12/11 2/6/2011 7/12/2011 22/08/11 26/08/11 19/10/11 14/10/11 5/10/2011 20/09/11 15/09/11 8/9/2011 30/10/11 30/10/11 20/10/11 3/7/2011 9/4/2011 14/04/11 23/04/11 20/05/11 30/04/11 3/8/2011 2/8/2011 13/06/11 31/12/11 30/06/11 22/07/11 24/07/11 21/12/11 15/02/11 28/05/11

Amount
455 584 373 294 502 313 860 514 566 542 642 1080 833 558 547 619 482 345 440 404 669 393 445 611 610 624 641 231 803 668

Nature of Expense
Medicine Medicine Medicine Medicine Medicine Medicine Medicine Medicine Medicine Medicine Medicine Medicine Medicine Medicine Medicine Medicine Medicine Medicine Medicine Medicine Medicine Medicine Medicine Medicine Medicine Medicine Medicine Medicine Medicine Medicine

Name of Patient
Raju.G S Raju.G S Raju.G S Raju.G S Raju.G S Raju.G S Raju.G S Raju.G S Raju.G S Raju.G S Raju.G S Raju.G S Raju.G S Raju.G S Raju.G S Raju.G S Raju.G S Raju.G S Raju.G S Raju.G S Raju.G S Raju.G S Raju.G S Raju.G S Raju.G S Raju.G S Raju.G S Bhagyalakshmi Bhagyalakshmi Bhagyalakshmi

Total Amount

16648

Declaration: I hereby declare that I understand the Medical reimbursement Policy and have read the notes below. The Bills claimed are incurred by me for self / depend and are Genuine in nature and for applicable financial year.
Note:

1 2 3 4 5 6

All the Fields in this Claim Form are mandatory Maximum allowable claim is Rs 15000/- PA or as per FBP declaration which ever is lower. Claim needs to be only for Self and dependants, Original Bills need to be attached All the Bills have to be from the date 01st April till 31st March of a financial year Medicines, Spectacles, Doctors fees are allowable, While cosmetics & non medical items are not allowed Please do not change the format of this claim form

Signature of the Employee

Include notes to the Payroll processor here (if any)

1. Please attach the medical bill along with claim sheet and submit the same in a closed envelop. 2 Mention the nature of claims & Employee code on the top of the envelop 3.Refer the medical reimbursement policy and read the foot notes

How Related
Self Self Self Self Self Self Self Self Self Self Self Self Self Self Self Self Self Self Self Self Self Self Self Self Self Self Self wife wife wife

dical reimbursement Policy and have read the notes below. The Bills claimed are incurred by me for self / dependants only year.

Include notes to the Payroll processor here (if any)