The Merchant Navy Officers Welfare Fund
Registered under Bombay public trust Act 1950, Register No: E/4771 of 1972 (BOM).

HOSPITALISATION TREATMENT REIMBURSEMENT FORM

THE MERCHANT NAVY OFFICERS' WELFARE FUND
"Udyog Bhavan", 4th Floor, 29 Walchand Hirachand Marg, Ballard Estate, Mumbai -400 001
Tel No: (91-22) 22619321 Fax: (91-22) 22644670 Email: mail@mnowf.com


For Office Use Only


Are you permanent employee of the Company? (Yes   /No   )

Are you on short Term Contract? (Yes   /No   )

Is your Company remitting donation to MNOWF Corpus on your behalf? (Yes   /No   )


Is the depenent Patient employed? (Yes   /No   )

(Officers' Bank details):


DETAILS OF MEDICAL EXPENSES

Sr No. Charges / Fee Amount
1 Registration Charges *
2 Stay / Bed Charages *
3 Doctors Visiting Fee(s) *
4 Consultation Fee(s) *
5 Operation Theater Charges *
6 Surgeon / Anesthetist Fee(s) *
7 Investigation Charges *
8 Medicine Charges *
9 Any other Medical Expenses *
Total *  Name of Doctor and Registration No.

I hereby declare that the above statement is true to the best of my knowledge and belief.


Instructions to be followed :

1. Details of Medical Expenses should be supported by relevant documents like Hospitalisation bill, Doctors prescription, Discharge Card, Investigation Reports, Medical Receipts and Cash Memos in Original (to expedite its settlement of your claim).

2. Separate Claim Form should be submitted for each illness.

3. In case of Maternity claim certified photo copy of Birth Certificate should be attached.

4. Officers are requested to submit photo copy of Leave Sanctioned Form , current year Provident fund statement and relevant page of CDC of last Vessel signed off while filling of Claim Forms.

5. Claim Form should be submitted within 90 days after completion of treatment.

6. The officer must ensure that Claim Form should be signed either by the Officer or in his absence by his wife.

7. Verification by the Doctor giving the diagnosis and period of treatment is a MUST for audit purpose.

8. Please intimate if you are receiving medical financial benefits for self and family from any other source(s). Please give details.

9. Officer's children's up to the age of 25 years are entitled for the Medical reimbursement benefits, subject to the condition that they are unmarried, unemployed and are solely dependent on him.

10. Parents, Brothers, Sisters and Relatives of Officer will not be entitled for the Medical benefits.

11. Reimbursement of medical expenses will be made by RTGS/NEFT only. Please ensure to submit correct details of your Bank Account.

12. Additional information pertaining to your Medical Claims may be furnish in a separate sheet or to be mentioned in covering letter for sake of clarification.

13. Medical Reimbursement Forms (Hospitalisation Treatment or Domiciliary Treatment) can be obtained from the Funds office on reauest or you can download Claim Forms from Website : www.mnowf.com

14. All correspondence relating to Medical claims should be sent directly to "The Merchant Navy Officers' Welfare Fund", Udyog Bhavan, 4th Floor, 29 Walchand Hirachand Marg, Ballard Estate, Mumbai - 400 001.


THIS CERTIFICATE TO BE SIGNED BY OFFICER OR HIS WIFE IN CLAIMS OF THEIR CHILDREN