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Medical Reimbursement Claim Form For Outdoor Treatment

Annexure - C to ( Order Dt. 22 April 2003 )

Claim Number 00000000000001911283 Personnel Number 00904740

1. Name Of Employee VIKAS SAINI

2. Designation TTA ENTERPRISE BUSINESS

3. Basic Pay + DA (as on 01-04-2017) 37471

4. Place Of Duty Gurgaon TD

5. Name Of Patient MOLISHA SAINI

6. Relationship with Employee Child

7. Age 002

8. Nature Of Illness General

9. Name Of Doctor/Hospital Arun K Saraf /

10. Details Of Claim : Date of Claim Submission Jun 6, 2017

(attach prescription, vouchers)

Voucher Date Claim Type Voucher No. Amount


Apr 15, 2017 Consultation 31198 500.00

Apr 24, 2017 Medicines 1611 44.00

TOTAL 544.00

Declaration : I hereby declare that the statements given in application are true to the best of my knowledge
and belief and that the person for which medical expenses are incurred is wholly dependent on me.

(Signature of Employee)

Mobile No. 0995813561

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