Tractebel Engineering pvt. ltd.

Name: Sumit Goel Department & Location:

Designation: Sr. Manager PBX Ext./Mobile:

Employee Code: 2015005

Relationship with
Date Name of the Patient Patient Age Name of the Doctor/H
Employee

4/23/2016 Baby Vaniya Goel 3 Father Manish/Cloudnine

5/29/2016 Baby Vaniya Goel 3 Father Manish/Cloudnine
2/12/2017 Baby Vaniya Goel 3 Father Manish/Cloudnine
7/2/2016 Baby Vaniya Goel 3 Father Manish/Cloudnine
9/24/2016 Baby Vaniya Goel 3 Father Manish/Cloudnine
10/18/2016 Baby Vaniya Goel 3 Father Manish/Cloudnine
9/17/2016 Baby Vaniya Goel 3 Father Manish/Cloudnine
10/2/2016 Baby Vaniya Goel 3 Father Manish/Cloudnine

I hereby certify that the above information is correct to the best of my knowledge.

Date Signature of Claimant

Checked & Verifyed by:

Accounts

GGNA-G-01136-123 Rev 00 F-123(a)_Medical Reimbursement

GGNA-G-01136-123 Rev 00 F-123(a)_Medical Reimbursement
 MEDICAL REIMBURSEMENT

Layout & Piping

593/ 8800478947

Amount Paid
Name of the Doctor/Hospital/ Store
(in Rs.)

Manish/Cloudnine Gurgaon 3438

Manish/Cloudnine Gurgaon 3240
Manish/Cloudnine Gurgaon 3609
Manish/Cloudnine Gurgaon 1850
Manish/Cloudnine Gurgaon 1650
Manish/Cloudnine Gurgaon 810
Manish/Cloudnine Gurgaon 1001
Manish/Cloudnine Gurgaon 3000

Total 18,598.00

Signature of Claimant

GGNA-G-01136-123 Rev 00 F-123(a)_Medical Reimbursement

GGNA-G-01136-123 Rev 00 F-123(a)_Medical Reimbursement