Sujit Arvind

00201101

GM

Medical Bill Reimbursement - Employee Claim Request

Claim Reference no: MDBLR0000032022

Class : Class I Grade : Grade E Contact no.: 9831436644 Prior Permission taken from BMO : Yes

Ailment : INJURIES Claim for : Dependent Dependent Name : Smt R Chaudhary Dependent Relation: Mother

Sr.no. Bill no. Bill Date Treatment Type Purpose Claimed amount Comments Approved amount

1 OPBL/20558765 Feb 8, 2020 OPD Doctor Fees 1600.00 INCLUDES RS.100 OF REGISTRATI

2 OPBL/20574822 Feb 17, 2020 Hospitalization Others 2550.00 AMBULANCE CHARGE

Total bill count: 2 Total Claimed amount : 4150 Additional Claimed Amount (If any) : 0
Signature : Date : No. of bills enclosed :

(For office use only)

BMO/BMC Signature : Approver 1 Signature : Remarks : Total approved amount:

Remarks : Approver 2 Signature : Remarks : Appr. Addl. Amt. (If any) : 0

Final Approved Amount ( Inc. Additional Amt. (If any) ) : 0 Total Amt.exempt from Tax ( Inc. Additional Amt. (if any) ) : 0.00

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