Yogesh Annexure
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ANNEXURE –1………………. VOUCHER –NO……………… Claim for reimbursement of medical expenses for the month……………………….under annual ceiling Name of Employee ……………… Designation…………….. Department……………………… personal No…………….. Basic pay+DP+DA (As on Ist OCT) S.NO. Name of patient
Relationship With the Employees
Cash Memo / Bill No.&/ date
Amount (Rs.)
Total…………. I declare that above mentioned person are member of my family and the dependent on me as per my declaration filled with company. Date: Place: Department Head: Signature of Employee …………………………………………………………………………………………. (For use in Administration Deptt.) Bill checked and found correct. Entered at page No……………………….. Passed for reimbursement of Rs.……………………….(Rupees…………………… ……………………………….). Assistant(P&A)
Dy.Manager(P&A)
For use in Accounts Deptt.) Passed for payment for Rs…………………………… …………………………………….). ACCOUNTANT
(Rupees ……………… SENIOR ACCOUNTANT
Relationship With the Employees
Cash Memo / Bill No.&/ date
Amount (Rs.)
Total…………. I declare that above mentioned person are member of my family and the dependent on me as per my declaration filled with company. Date: Place: Department Head: Signature of Employee …………………………………………………………………………………………. (For use in Administration Deptt.) Bill checked and found correct. Entered at page No……………………….. Passed for reimbursement of Rs.……………………….(Rupees…………………… ……………………………….). Assistant(P&A)
Dy.Manager(P&A)
For use in Accounts Deptt.) Passed for payment for Rs…………………………… …………………………………….). ACCOUNTANT
(Rupees ……………… SENIOR ACCOUNTANT
