MEDICAL EXPENSES CLAIM/चिकित्सा व्यय दावा प्रपत्र | National Foundation For India

Name of the NGO worker/volunteer *

Name of the NGO and Address *

Father’s/Mother’s Name

Sex

Designation *

Photo

Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png.

Claimant Address *

District/Village *

PIN *

Phone No. *

Last Drawn Salary

Name of the treating doctor *

Name of the hospital (if admitted)

Covid test done *

Yes

No

Date of Covid test

Insurance status *

Yes

No

Total Expenditure

Medicines *

Consultation *

Test *

Have received money from any other sources

Yes

No

If Yes, source

and amount

Name of Head of the NGO referring case

Upload document

Hospital discharge slip *

Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png pdf doc docx.

Medicalbills

Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png pdf doc docx.

Aadhar/PAN/Driving licence for identification *

Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png pdf doc docx.

Pan Card of Applicant *

Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png pdf doc docx.

Proof of being a worker during the COVID period (Preferred Attendee/Bank statement)

Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png pdf doc docx.

COVID positive report if available

Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png pdf doc docx.

Reference letter of NGO where person worked/served *

Files must be less than 2 MB.
Allowed file types: gif jpg jpeg png pdf doc docx.

declare

I hereby declare that the information provided is true and correct. I also understand that any wilful dishonesty may render for refusal of this application.