Sindoori Management Solutions Private Limited

OUT PATIENT MEDICAL REIMBURSEMENT CLAIM APPROVAL FORM

Unit: APOLLO
Employee id No: Designation: Biomedical
Name: Nirupam Das MULTISPECIALTY Claim for the Month of:
FSMS06983 Engineer
HOSPITAL KOLKATTA

Details of
Sl.No Claim Favouring Amount(Rs.)
Bill(Original+Prescription)

1 09 Spouse 8169.00

Total No of Bills: 1 Total Amount:Rs: 8169

Signature of the Claimant: Date of Submission: 26/06/2024

ACTION BY HRD:

Amount Claimed as on
Claim Recieved On: Total Eligibility: Available Balance:
Date(Including this Claim):

Bills Received & Processed by:HQ -HR Recommended by:HRD Approved by:

Name: Name: Name:

Designation: Senior Executive Designation: Designation:

Signature: Signature: Signature:

Date: Date: Date:

Note: 1. Outpatient medical reimbursement claim is applicable to only Non ESI coverage staff
2. Coverage: If Married (Self + Spouse and 2 Children) and If unmarried (Self + Father & Mother) only

Reference No.HRD(T&C)605 - F1 Revision No:D Effective Date:16/06/2016