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

DOMICILIARY TREATMENT REIMBURSEMENT FORM

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


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   )


On Authorised Leave :


Is the depenent Patient employed? (If yes)

Hospitalised

(Officers' Bank details):



(D)
DETAILS OF MEDICAL EXPENSES
Sr No. Name Amount Claimed Amount Admissible Remarks
1 Consultation Charges
2 Visit No and Rate
3 Medicines: Given by Doctor Purchase from Outside
4 Investigations
DENTAL EXPENSES
1 Consultation Charges
2 Extraction No and RS
3 Filling, Partial Denture or Treatment of any other nature
4 X-ray


(To be completed by the Attending Doctor)

Duration Illness

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



(For Office Use Only.)

Payment Details




Instructions to be followed:


1. Please attached Original Receipts for Consultation, Investigation and Medicines and also Prescription, Investigation reports to enable us to expedite settlement of claim(s). (refer Section "D" & "E").

2. Please ensure that Section "F" is certified / stamped / signed by Medical Practitioner to avoid delay.

3. No claim below Rs. 1000/- will be entertained.

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

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

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

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

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

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

10. Officer's children 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 Officer.

11. Parents, Brothers, Sisters and Relatives of Officer are not eligible for the Medical benefits.

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

13. 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.

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

15. 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