MEDICAL EXPENSES CLAIM-CUM-VOUCHER-00000000000008772371/31.07.

2021

Employee No 00059487 Employee Name Arun Kumar Kar

Designation Chief Inspection Manager Grade E
Department Inspection Location Haldia Refinery
Contact No./Address Tel No. : 03224 - 223678 ; Mobile No. : 919635721341
QTR No. 12/29 HALDIA REFINERY TOWNSHIP Haldia

Document Type Ref. by CMO/AMA Employee No. -00059487

MedOutstn. Decl. No.
Treatment Category Company Doctor
Treatment Availed As Out Patient
Advance No. (if taken) Claim Ref. No. 8772371/31.07.2021
Time Barred claim
Claim Details

Patient Name Doctor/Hospital Name Bill Date Bill No Covid Type Bill Amount
Aaradhya Kar DR. D. CHAKRABORTY,Haldia 139 No Consultancy 400.00
Refinery 11.10.2020
Aaradhya Kar DR. D. CHAKRABORTY,Haldia 26497 No MEDICINES 111.00
Refinery 15.10.2020
Arnish KAR DR. D. CHAKRABORTY,Haldia 792 No Consultancy 400.00
Refinery 20.11.2020
Arnish KAR DR. D. CHAKRABORTY,Haldia 1118 No Consultancy 300.00
Refinery 04.02.2021
Bill Amount (Rs) 1,211.00 (ONE THOUSAND TWO HUNDRED ELEVEN ONLY)

Claim Amount (Rs) 1,211.00 (ONE THOUSAND TWO HUNDRED ELEVEN ONLY)

Number of Enclosure : 11

DECLARATION : I hereby declare that the above statements are true and the person for whom medical expenses have
been claimed are wholly dependent upon me and are residing with me under the same roof. I certify that the medicines
shown against the bill(s) above are not for a period of more than one month.

Signature of the Employee

Date Approved By Designation : Status

Pending for Approval
FOR OFFICE USE
Passed for Amount (Rs.) : 0.00 Signature/Date
ONLY

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