Hospitalisation Treatment

THE MERCHANT NAVY OFFICERS' WELFARE FUND
"Udyog Bhavan", 4th Floor, 29 Walchand Hirachand Marg, Ballard Estate, Mumbai -400 001
Tel No: (91-22) 22619321, 022-49680968 Fax: (91-22) 22644670 Email: mail@mnowf.com

For Office Use Only

Inward Date :

Inward No. :

By :

Claim No. :

IN CAPITAL LETTERS - Please fill the Form correctly after reading the instruction : (Over Leaf)

Officer's Name * :

Rank * :

Name Of Company * :

Initial Date of Joining * :

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 )

Are you member of Company's Provident Fund? (If Yes) Provident Fund Account No.

Ship's Name * : (Attach photo copy of relevat page of CDC for audit prupose)

Date of Signed Off * :

Your MUI Membership No. (If any) * :

on Authorised Leave from * :

To * :

Name of the Patient * :

Date of Birth * :

Relationship * :

Nature of Illness * :

Is the depenent Patient employed? (Yes /No )

Name of the Employer * :

Hospitalised from * :

To * :

Name & Address of the Hospital * :

(Officers' Bank details):

Name of the A/c Holder * :

IFSC Code * :

A/c No. * :

Name of the Bank * :

Name of the Branch * :

Bank Address * :

Residence Address * :

Pin code * :

Tel No. * :

Mobile No * :

Email ID * :

DETAILS OF MEDICAL EXPENSES

Name of the Hospital * :

Date of Admission * :

Date of Discharge * :

Diagnosis * :

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.

Total Amount of this Claim is Rupees :

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

Date : *

Signature *
(Officer / Wife)

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

Certificate that my son/daughter :

Age :

is unmarried,unemployed and solely dependent on me.

Date :

Signature
(Officer / Wife)

Sr No.	Charges / Fee
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.

HOSPITALISATION TREATMENT REIMBURSEMENT FORM

(Officers' Bank details):