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