MONSANTO INDIA LIMITED

Ahura Centre, 5th Floor, 96, Mahakali Caves Road, Andheri (E), Mumbai 400 093
FOR DOMICILIARY EXPENSES
Employee Name : SANTHOSH KUMAR N
Employee ID /SAP ID: sskuma5
Cost Center: MEL74701
Designation : Unix Administrator
Department : EIT
Tel. No: 09945696607

Name of the Patient : BHAGIRATHI

Age :
58
Relation ship
MOTHER
Nature of Ilness : Dental problem

I am making this claim for Domiciliary Treatment as per details given below. I hereby declare that all
statements made by me are true in every respect and are made without any reservation. I also
declare that I do not get nor am I likely to get any medical benefits for this illness from any other
source. I understand that the reimbursement received is fully taxable.
In support of the claim, I am attaching the following documents:
a)
b)
c)

Attending Doctors/Consultants/Surgeons bill.

Chemist bills supported by doctors prescription.
Bill/receipt from pathologists together with report.

STRIKE OUT WHATEVER IS NOT APPLICABLE.

----------------------------Date

Particulars
a)

Consultants fees

b)

Family Doctors fees

c)
d)
e)
f)

----------------------------------SIGNATURE OF EMPLOYEE

Amount
Incurred (Rs.)
7500

Medicines given by Family

Doctor
Medicines brought from
Chemists (Bills attached)
Investigations
bill
and
Reports attached
Others
TOTAL
LESS EXCESS
NET AMT. PAYABLE

7500

Amount of
claim admissible
(Rs.)

Amount to be
borne by the
Employee (Rs.)

Remarks