FOR OFFICERS

Reimbursement of Medical Expenses for Self and Family for the Financial year : 2021

You are requested to Please Attach a Copy of Prescription along with Original Bills / Cash Memos

Employee Name:S Shankar Anand To: Medical Co-ordinator : Kutty C Sankaran (23063352)

Token Number: 23163937 Dept. Name: Engines FD, Chennai

Contact No: 9840222527 PA: TRK PTD ADV TEC & MRV CMN SRV Date : 31-Jan-21

Claim No: 2316393700032 Grade: L7-Operational Cost Center :FP1124

Kindly arrange to reimburse the Medical Expenses incurred by me as per details given below:

Reimbursement towards Spectacle Expenses

Sr. No Bill. No Date Name of the Chemist/Doctor/Clinic Name: Self/Spouse/Child Amount(Rs.)

1 786 24/01/21 LensKart Spouse Naga Usha S 839.00

Amount Sanctioned: 839.00 * Amount Applied: 839.00

* Subject to Approval

Employee Signature

Remarks of the
Medical Officer:
Employee token No. 23163937

Please forward the bills/prescriptions to the Medical Co-ordinator along with this form.