Annexure A

CLAIM FORM FOR EXPENDITURE ON DOMICILARY TREATMENT FOR THE QUARTER ENDED on:
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NAME : EMP NO. _______

GRADE:

Date of Cash Memo / Description Prescription / Prescribed for Amount (in INR)
Bills (Consultation, Visits, Consultation (Name of the Patient)
Medicine) (Name of the Doctor)

Claimant’s Signature: Total of all claims

N.B.: CASH MEMOS/ BILLS & RECEIPTS TOGETHER WITH DOCTOR’S PRESCRIPTION MUST BE ATTACHED WITH
THIS CLAIM FORM
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(FOR INTERNAL USE)

Approved by :……………………… Claim Allowed:

……………………………………

RECEIVED Rs. …………………. (Rupees …………………………………………………………)

(To be retained for one year).