Free form template · Word

Medical Expense Claim Form

A medical expense claim form lets an employee recover a specific, one-off medical cost that the company has agreed to bear, such as treatment for a minor workplace injury, a company-mandated medical test or vaccination. It links each claim to the reason the company is paying and to an approver.

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[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]

Incident or Requirement Details

Date and Place
Brief Description
Treated At (clinic / hospital)
Approved in advance by

Expense Details

Date	Description	Bill / Receipt No.	Amount (₹)
[DD/MM/YYYY]	[Consultation / Test / Vaccine]	[Bill No.]	[Amount]
[DD/MM/YYYY]	[Medicines]	[Bill No.]	[Amount]
[DD/MM/YYYY]	[Local conveyance to clinic]	[Bill No.]	[Amount]
	Total		[Amount]

Declaration

I confirm that these expenses were incurred for the reason stated, that I have not been reimbursed under ESI, insurance or any other source for the same expense, and that the receipts attached are genuine.

Employee
[Employee Name]
Date: [Date]

Reporting Manager
[Reporting Manager]
Date: [Date]

HR
[HR Name]
Payment Mode: Payroll / Bank Transfer

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What this template includes

Reason category showing why the company is bearing the cost
Incident reference for workplace injuries
Itemised expense table
Check that the expense is not claimable under ESI or insurance
Approval by the reporting manager and HR
Payment mode and timeline

When to use it

First-aid or clinic treatment after a minor injury at the workplace
Pre-employment or periodic medical tests paid by the employee upfront
Vaccinations required for business travel
Medical costs incurred while on official travel

How to customise this template

1List the situations your policy covers under this form
2Link the injury section to your incident report number
3Add a cost cap that does not need senior approval
4Insert your accounts team's processing timeline

HR tips

For ESI-covered employees, treatment for employment injury is normally through ESI; check before reimbursing privately
Always cross-reference a workplace injury with an incident report
Settle mandated test costs quickly, they are a company requirement
Do not use this form for routine OPD bills; use the medical reimbursement form

Workplace injuries may trigger obligations under ESI, employee compensation and state rules. Review the process with your safety team and legal adviser.

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Frequently asked questions

Who pays for an employee's medical test required by the company?+

Usually the employer, since the test is a company requirement. The employee can claim it back using this form if they paid upfront.

Is a minor workplace injury claimed through ESI?+

For ESI-covered employees, employment injury benefits are generally provided through ESI. Non-ESI employees may be covered by the company's employee compensation or accident policy.

How long does medical expense reimbursement take?+

That depends on company policy; many firms pay with the next payroll or within a fixed number of working days of approval.

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[Company Logo][Company Name]
HEALTH INSURANCE CLAIM SUBMISSION FORM (INTERNAL)
Company:
[Company Name]
Insurer / TPA:
[Insurer Name] / [TPA Name]
Policy No.:
[Policy Number]
Internal Claim Ref.:
[Reference Number]
Date of Submission:
[Date]
Important: This form helps HR process your claim. The insurer's or TPA's official claim form must also be completed, signed and attached where required.
1. Employee Details
Employee Name
Employee ID
Department
Mobile Number
Email ID
2. Patient Details
Patient Name
Relationship to Employee
Age
E-card / Member ID
TPA Claim Intimation No. (if any)
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[Company Logo][Company Name]
INSURANCE CLAIM ASSISTANCE REQUEST
Company:
[Company Name]
Request No.:
[Reference Number]
Date:
[Date]
Priority:
Urgent (in hospital) / Normal
Employee and Policy
Employee Name
Employee ID
Department
Mobile Number
Policy Type: Group Health / Group Personal Accident / Group Term Life
Patient / Insured Member Name
TPA / Insurer Claim Number
Nature of Assistance Needed
- Cashless approval pending
- Reimbursement claim delayed
- Claim rejected, request review
- Claim partly settled / deductions unclear
- Document query from TPA
- Other: [Details]
Claim Summary
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Patient Name
Relationship to Employee
Age
E-card / Member ID
TPA Claim Intimation No. (if any)

Annual Limit (₹)	Claimed So Far (₹)	This Claim (₹)	Balance After Claim (₹)
[Amount]	[Amount]	[Amount]	[Amount]

[Company Logo][Company Name]

HOSPITALISATION INTIMATION AND CLAIM FORM

Company:: [Company Name]
Policy No.:: [Policy Number]
TPA:: [TPA Name]
TPA Intimation No.:: [Reference Number]
Date:: [Date]

Note: This internal form helps HR support your claim. The hospital's pre-authorisation request and the insurer's or TPA's claim form must also be completed where required.

Employee and Patient

Employee Name
Employee ID
Mobile Number
Patient Name
Relationship
E-card / Member ID

Admission Details

Admission Type: Planned / Emergency
Hospital Name and City
Network Hospital: Yes / No
Treating Doctor
Diagnosis / Proposed Procedure
Date of Admission
Expected Length of Stay (days)
Room Category Opted
Room Rent Eligibility as per Policy: ₹[Amount] per day

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Hospitalization Claim Form

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[Company Logo][Company Name]
PERSONAL ACCIDENT CLAIM FORM (INTERNAL)
Company:
[Company Name]
GPA Policy No.:
[Policy Number]
Insurer:
[Insurer Name]
Internal Ref.:
[Reference Number]
Date:
[Date]
This form supports HR in filing the claim. The insurer's official claim form must also be completed and signed by the insured or claimant.
1. Insured Employee
Employee Name
Employee ID
Designation
Department
Date of Birth
2. Claimant (if not the employee)
Claimant Name
Relationship to Employee
Nominee as per records: Yes / No
Mobile Number
Address
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Claimant Name
Relationship to Employee
Nominee as per records: Yes / No
Mobile Number
Address

[Company Logo][Company Name]

TRAVEL EXPENSE CLAIM

Company:: [Company Name]
Claim No.:: [Reference Number]
Travel Approval / Advance No.:: [Reference Number]
Date:: [Date]

Employee and Trip

Employee Name
Employee ID
Grade
Department
Cost Centre
Purpose of Trip
Places Visited
Departure	[DD/MM/YYYY] [HH:MM]
Return	[DD/MM/YYYY] [HH:MM]

Day-wise Expense Sheet

Date	City	Fare (₹)	Hotel (₹)	DA (₹)	Local Travel (₹)	Other (₹)	Bill / GST Invoice No.
[DD/MM/YYYY]	[City]	[Amount]	[Amount]	[Amount]	[Amount]	[Amount]	[Invoice No.]
[DD/MM/YYYY]	[City]	[Amount]	[Amount]	[Amount]	[Amount]	[Amount]	[Invoice No.]
[DD/MM/YYYY]	[City]	[Amount]	[Amount]	[Amount]	[Amount]	[Amount]	[Invoice No.]
Total		[Amount]	[Amount]	[Amount]	[Amount]	[Amount]

Settlement

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[Company Logo][Company Name]
EXPENSE REIMBURSEMENT CLAIM
Company:
[Company Name]
Claim No.:
[Reference Number]
Claim Period:
[Month]
Date:
[Date]
Claimant
Employee Name
Employee ID
Department
Cost Centre / Project Code
Reporting Manager
Expense Categories
- C1 Client entertainment
- C2 Courier and postage
- C3 Stationery and printing
- C4 Software and subscriptions (pre-approved)
- C5 Team supplies and refreshments
- C6 Other (specify)
Expense Details
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Expense Approval Form
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Expense Type: Team Event / Training / Client Gift / Purchase / Other
Description
Business Justification
Date Required By
Number of Beneficiaries / Attendees

Medical Expense Claim Form

Preview of the form

Claimant Details

Reason for Claim (tick one)

Incident or Requirement Details

Expense Details

Declaration

What this template includes

When to use it

How to customise this template

HR tips

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Frequently asked questions

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