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  • Outpatient Claim Form

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    Hira Raza
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    This document is an outpatient claim form submitted by Hira Raza, an employee of Tapal Tea Pvt Ltd, to New Jubilee Insurance Company for reimbursement of medical expenses totaling Rs. 8,887. It includes bills from Memon Medical Institute & Hospital for various visits between June 19-27 for fees of Rs. 1,333, Rs. 3,000, Rs. 940, Rs. 2,481, and Rs. 544. The form requires the employee's signature, employer verification, and attachment of original bills, prescriptions, and medical reports.

    Original Description:

    HRM

    Original Title

    NJI OPD form

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    This document is an outpatient claim form submitted by Hira Raza, an employee of Tapal Tea Pvt Ltd, to New Jubilee Insurance Company for reimbursement of medical expenses totaling Rs. 8,887. It includes bills from Memon Medical Institute & Hospital for various visits between June 19-27 for fees of Rs. 1,333, Rs. 3,000, Rs. 940, Rs. 2,481, and Rs. 544. The form requires the employee's signature, employer verification, and attachment of original bills, prescriptions, and medical reports.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    72 views1 page

    Outpatient Claim Form

    Uploaded by

    Hira Raza
    This document is an outpatient claim form submitted by Hira Raza, an employee of Tapal Tea Pvt Ltd, to New Jubilee Insurance Company for reimbursement of medical expenses totaling Rs. 8,887. It includes bills from Memon Medical Institute & Hospital for various visits between June 19-27 for fees of Rs. 1,333, Rs. 3,000, Rs. 940, Rs. 2,481, and Rs. 544. The form requires the employee's signature, employer verification, and attachment of original bills, prescriptions, and medical reports.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    Tel : 2416022-25

    NEW JUBILEE INSURANCE COMPANY LIMITED Fax


    Website
    : 2438738 & 24
    : www.nji.com.pk
    Jubilee Insurance House, I. I. Chundrigar Road, P.O. Box 4795, Karachi-74000. Pakistan.
    E-mail : nji@cyber.net.p

    OUT PATIENT CLAIM FORM

    Dated: _____15-07-2020________
    For office use only
    Claim
    Amount
    Approved
    Amount
    COMPANY NAME: Tapal Tea Pvt Ltd
    Deducted
    Admission Amount
    / - 0 0 0 0
    Letter No.
    Reason (S)
    Employee’
    s Hira Raza
    Check By
    Name

    Name of Medical Practitioner/ Physician’s Amount


    S. No. Bill No Date
    Medical Store Fee per Visit Rs.
    01 I012006278257 19/06/2020 Memon Medical Institute & hospital 1333

    02 V012006549867 19/06/2020 Memon Medical Institute & hospital 3000

    03 V012006571563 27/06/2020 Memon Medical Institute & hospital 940

    04 I012006278969 27/06/2020 Memon Medical Institute & hospital 2481

    05 I012006279020 27/06/2020 Memon Medical Institute & hospital 544

    06 V012006571365 27/06/2020 Memon Medical Institute & hospital 589

    07
    08
    Total

    Amount in words: Eight thousand eight hundred and eighty-seven rupees only
    I hereby declare that the amount stated above is correct and was incurred by me for medical expenses.

    ___________________________
    Signature of Employee _________________________________
    Verification of Employer with Seal

    Note: Please attached:


     Proper Original bills/receipts.
     Doctor’s Prescription (copy) in support of medicines purchased.
     Copy of reports/diagnosis and related documents (if any)

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