SELF DECLARATION

This is to certify that I have been suffering from_____________________ (name of illness) and
hospitalized or require hospitalization in ____________________________________ (name of hospital)
lasting for one month or more.

OR

I have to undergo for major surgical operation for the treatment of ______________________(name of
illness) in ___________________________(name of hospital).

OR

I have been suffering from T.B., Leprosy, paralysis, cancer, mental derangement or heart ailment and
under treatment in __________________________________(name of hospital).

As per Dr. ___________________ of the above said hospital, total expenditure for the treatment shall
be Rs. _________ approximately.

(signature of the employee)

Employee Code ___________

SELF DECLARATION (FOR MEDICAL TREATMENT OF FAMILY MEMBER)

This is to certified that my wife/son/daughter/dependent father/mother Shri/Smt. ________________

has to undergo for major surgical operation for the treatment of __________________ and hospitalized
or require hospitalization in ____________________________________(name of hospital) for one
month or more.

OR
He/She has been suffering from T.B., Leprosy, paralysis, cancer, mental derangement or heart ailment
and is under treatment in ____________________________________________(name of hospital).
He/She has been hospitalized or require hospitalization for one month or more.

As per Dr. ___________________ of the above said hospital, total expenditure for the treatment shall
be Rs. ____________ approximately.

(Signature of the Employee)

Employees Code __________