Medical Reimbursement Format in doc

Sample Template Example of Medical Reimbursement Format in doc in Word / Doc / Pdf Free Download

X Company

Date: ________________

DECLARATION FORM FOR CLAIMING REIMBURSEMENT OF MEDICAL EXPENSES

Period: From ___________________________ To _______________________ )

To: HR Department,

Name: _________________________________________ Code No.: _________________________

Designation: ____________________________________ Section:    _________________________

DETAILS OF MEDICAL EXPENSES INCURRED

Relationship	Name	Consul	Medicine	Tests	Total
Self
Spouse
Child i)          ii)         iii)
Grand Total

I hereby request you to reimburse me the amount of Rs. ______________ stated above.

Signature of Employee ______________________                         Bills are enclosed

(For Use by Human Resources Department)

Entitlement                                                                 : Rs. ____________________________

Amount already claimed                                            : Rs. ____________________________

Amount claimed as per the application form            : Rs. ____________________________

Amount to be reimbursed                                          : Rs. ____________________________

Balance Carried Forward                                          : Rs. ____________________________

Checked By:                                                                          Sanctioned By:

 

(For Use by Accounts Dept.)

Received Rs. ____________ (Rupees _______________________________________________)

(Employee Signature)

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