MEDICAL REIMBURSEMENT CLAIM

Emp No. N215 Claim No. 1 Date: 04-Feb-2014 Category: IDA File No/Ref. No. _________________
Name: YOGESHWAR MAURYA (!"#$ &' ()* )
Location: GURGAON COMPLEX
I Com:
Level: 10 Division: TRAINING ()
Residential Address of Employee: , , ,
Name of Patient & Relationship: YOGESHWAR MAURYA, SELF
Place where Patient fell Sick: AT RESIDENCE
Reason if Residential station and place of sickness is different:
Type of Treatment: INDOOR TREATMENT
Type of Illness: GENERAL Treatment in: NOMINATED
HOSPITAL
Tax Exemption Sought: Yes
Admit on: 19-Jan-2014, Discharge on: 21-Jan-2014
Details of Claim:
Consultation Charges
Date Receipt No Place/Remarks Amount Claimed Disallowed
19-1-2014 IR1301603
Sheetla Hospital,
Gurgaon
14,618.00
14,618.00 Sub Total
- I am a member of Company's Medical Scheme.
- I also certify that Shri/Smt. XXXXXXX is my wholly dependent parent residing with me/not residing with me. The total average
income of my dependent parents does not exceed Rs.5,000/- p.m. (or Rs. 60,000/- p.a.) from all sources, as contained in Medical Rules.
- The person for whom the Medical expenses were incurred is a member of my family as defined under medical rules.
- I hereby declare that the statements made in the claim are true to the best of my knowledge and belief.
DECLARATION BY CLAIMANT
Emp Sign.:________________ Name : YOGESHWAR MAURYA(!"#$
&
' ()* ) Emp.No. : N215
Date : 04-Feb-2014
14,618.00
Grand Total
Page 1 of 1