Annexure -C

Contributory Scheme for Post Retirement Medical Facilities for Employees

CLAIM FORM FOR REIMBURSEMENT OF MEDICAL EXPENSES

INCURED BY
RETIRED EMPLOYEE/SPOUSE

Medical Card No.___________

Name & Grade of the Employee who has retired Emp.No. Last Pay Drawn

Present Postal Address__________________________ Vendor code _____________________

______________________________________________ IFCI Code ______________________

______________________________________________ ECS A/C No ______________________

Mob.No._______________________________________ SB A/C No ________________________

DETAILS OF AMOUNT CLAIMED OPD

Consultation Cost of Investigation/
Name of Hospital Doctors Bill No. & Amount Medicines Path charges
Patient' Name & Relation & Doctor Qualification Date 1 2 3

TOTAL 1+2+3 IN Rs.

i) The statements made in the claim are true to the best of my knowledge and belief.
ii) I am a member of Contributory Scheme for Post Retirement Medical Facilities,/incase of death
of serving employee and my Medical Card is valid up to ______________________________
iii) I continue to fulfill the conditions of eligibility for availing the benefits under the scheme.
iv) The Medical expenses were incurred for self/spouse..
v) I fully understand that Company may refuse / terminate my membership of the scheme at any time
without any notice and without assigning any reasons.

Dated:__________________ (SIGNATURE OF THE R