|
|
|
APPLICATION FOR REIMBURSEMENT OF HOSPITALISATION EXPENSES UNDER C.B.O.O. BENEVOLENT FUND - FOR DEPENDANTS AND SELF TO :
THE SECRETARY, BENEVOLENT FUND, CBOO, Central Office, Mangalore 1. Name & E.No. : __________________________ 2. Branch/Office : __________________________ 3. Whether for Self : YES / NO (applicable only w.e.f. 1.10.2004) 4. Name of the Dependent :__________________________ (On whose hospitalization reimbursement is claimed) 5. Relationship with the Applicant :__________________________ 6. Nature of illness/ ailment :___________________ 7. Whether eligible for reimbursement : YES / NO under Staff Welfare Scheme If YES - reimbursement claimed/ : Rs_________________ Sanctioned.
I am a member of CBOOBF and there is no default in payment of my subscription to CBOOBF. I enclose all original sanctions from Bank / Staff Welfare Fund / Other for the purpose. Kindly sanction eligible amount.
( SIGNATURE OF THE APPLICANT ) Place : Date : / / 200
Enclosure * Original sanction of Reimbursement Hospitalisation Expenses by Bank. * Original sanction of Reimbursement Hospitalisation Expenses by Staff Welfare Fund. ___________________________________________________________ FOR CENTRAL OFFICE USE APPLICATION RECEIVED ON / / 200 PAYMENT SENT ON / /200 by Ch.No……………. Dtd…………….
|
|
|
