[Company Logo][Company Name]
MEDICAL EXPENSE CLAIM FORM
- Company:
- [Company Name]
- Claim No.:
- [Reference Number]
- Date:
- [Date]
Claimant Details
| Employee Name | |
|---|---|
| Employee ID | |
| Department | |
| Work Location | |
| ESI Covered: Yes / No |
Reason for Claim (tick one)
- Minor injury at workplace, Incident Report No. [Reference Number]
- Company-mandated medical test (pre-employment / periodic / food handler)
- Vaccination required for official travel
- Medical treatment during official travel
- Other approved reason: [Details]