This document is an out-patient claim form for reimbursement of medical expenses from a company's insurance provider. It requests information such as the employee and policy details, bills and receipts for medical expenses, and signatures from the employee and employer certifying the accuracy of the claimed expenses. Supporting documents like diagnosis reports and prescriptions must also be attached for approval and reimbursement of the expenses.

1. OUT-PATIENT CLAIM FORM
COMPANY NAME: FOR NJI USE ONLY
POLICY NO : Date: Entry No.
EMPLOYEE NAME: Claimed :
COMPANY ID NO: NJI-INSURED-ID Approved :
BANK A/C NO: (Not compulsory) Deduction:
Claimed Amount NJI Approved
Sr.No Bill No. Date Name of Consultant OR Medical Store Family Self per receipt
( dd/mm/yy )
1
2
3
4
5
6
7
8
9
10
11
12
Sub Total =================================>
Grand Total ================================>
Amount in words :
I hereby declare that the amount stated above is correct and was incurred by me for medical expenses.
Employee's Signature Employer's Signature with Seal

2. DOCUMENTS TO BE ATTACHED
* Proper Original Receipts / Bills of attending Physicine with detail of charges.
* Proper Original Receipts/Bills showing name of drugs & quantity along with Supporting Prescriptions,Diagnosis report, Lab test and X-rays etc.
DOCTOR'S REMARKS