Note of Claim

THE MERCHANT NAVY OFFICERS' WELFARE FUND (MNOWF)
Udyog Bhavan, 4th Floor, 29, Walchand Hirachand Marg, Ballard Estate, Mumbai 400 001.
Tel.: 91-22 / 2261 9321 Fax : (91-22) 2264 4670 E-mail : mail@mnowf.com Web : www.mnowf.com
Note: This Notice Of Claim must be sent to the Fund within a week after Completion of Treatment for Claiming Reimbursement

Name * :

Rank * :

Employee Code No * :

Date of Joining Company * :

Name of INSA Memberline Company Employed With * :

Name of last Ship And Date of Sign-Off * :

Total Period ashore after last sign-off (months. & days) * :

Permanent Residential Home Address * :

MEDICAL EXPENSES REIMBURSEMENT

OFFICER

WIFE

CHILD

Treatment Taken

In Hospital

Domicilliary

Dental

Treatment Started On * :

Date * :

Name of Person Covered * :

Wife / son / daughter of * :

Nature of illness * :

Treatment taken from : (Name and complete address of hospital or doctor) * :

After recover from illness I will submit claim in the prescribed manner alongwith all the original documents Is your wife employed ? If yes, give office name and address * :

Date * :

Signature of Officer / Wife * :

For Office Use Only :

RECEIVED ON:

Inward No:

BY:

NOTICE OF CLAIM FORM