Employee Name

John Smith

ID

Department

Contact 

Date of Visit

Doctor / Clinic /

Hospital Name

Reason for Visit

Total Amount Claimed

Insurance Provider

Policy Number

I hereby declare that the information provided above is accurate to the best of my knowledge and that the medical expenses were incurred by me or my dependents. I understand that any false claims may result in disciplinary action.

[Employee Signature]

[Date]

Received by

[HR Name and Signature]

Processed by

[HR Name and Signature]