HEAD (HR/BE)

JAMIPOL Limited
Jamshedpur.
Dear Sir,
Sub : Reimbursement of medical expenses
I hereby submit my family details along with photographs for the purpose of medical
reimbursements :
FAMILY DETAILS
Name

Relationship
with the
employee

Date of Birth

Idfn. mark

Blood
Group

Family means spouse, unmarried daughters, dependent sons upto 25 years of age and
dependent parents.
Signature

Name

Designation

Date of joining :
P. No.

Date : ./../..