GUJARAT INDUSTRIES POWER COMPANY LIMITED

Surat Lignite Power Plant

(Revised)
REIMBURSEMENT OF MEDICAL EXPENSES 30/09/2014
To
H R & Admn. Department
Please Tick mark whichever is applicable below :-

(1)Long Term Treatment, Regd. No. (2) Hospitalization :From _to _

(3) Pre. / Post Hospitalization: (4)Vaccination

(5) Dental / ENT / Ophthalmology/ Orthopedic (6) Other

(A) DETAILS OF EMPLOYEE :

1) Name of the Employee:

2) Emp. Code No. Designation ------------------------------------------------------ Grade:----------------------

3) Dept: Int. Ph. No. Mobile No.

(B) DETAILS OF TREATMENT

Name of Patient : Relationship :

Age: Name of Diseases / Treatment :

Duration to_ Days

(C) CHARGES FOR TREATMENT (original Receipt/Bills, Prescription, Copy of reports to be attached)

1. CONSULTATION CHARGES
Date Receipt No. Name of Hospital / Doctor Amount

2. LABORATORY / X-RAY / SCREENING INVESTIGATION

Date Receipt No. Name of Hospital / Lab/ Radiology clinic Amount

3. MEDICINES :
Date Bill No. Name of Hospital / Doctor Pharmacy Amount

Total of First Page C/F Rs.

NB:- Please Submit the Medical Claim Form well in time. (PTO)
 ..2..
Total of First Page B/f Rs.

4. HOSPITALISATION CHARGES :

A No. of days _ / Rate / Day Rs.

B Nursing Charges Rs.
C Professional Charges (Visit Charges) Rs.
D Anesthesia Charges Rs.
E Operation Charges Rs.
F Operation Theater Charges. Rs.
G Medicine Supplied by Hospital Rs.
H Any Other Charges Rs.
I Rs.
J Rs.
K Rs.
TOTAL (A to K) Rs.

Total claim amount RS.---------------------------

DECLARATION BY THE CLAIMANT

I hereby declare that the person for whom the medical expenses are incurred is a member of my
th
family and dependent on me as mentioned in the Circular dt 24 Sept 2014. I further confirm that
he/she is satisfying the Company’s requirements to be my dependent. Any suppression of
material facts contained or willful concealment of any fact will render me liable for appropriate
disciplinary action including termination of my employment

NB. I have taken an Advance Rs. on Dt. Request to settle against my Final
Claimed Amount and pay the balance amount.

Date : Signature of Employee

---------------------------------------------------------------------------------------------------------------------------------------
FOR THE USE OF HR & ADMN DEPARTMENT

Remarks of Company Doctor

Signature of Co';s Doctor

Claim Amt.

Deduction Amt.

Sanction Amt. _

Checked By

Mgr (HR&A) Sanctioning Authority

DGM (HR & A)
FOR THE USE OF FINANCE DEPARTMENT
Bills Approved for Rs. (Rupees )

Approved by. :