Medical Reimbursement Format in doc

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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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