Medi-Claim Form Page 5

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ANMOL MEDICARE LTD.
STATEMENT OF BILLS
NAME
D.0.A.
D.O.D.
POLICY NO.
PERIOD :
FROM:
TO:
SR. NO
DESCRIPTION
BILL NO.
DATE
AMOUNT
A DOCTORS & HOSPITAL BILLS
SUBTOTAL (A)
B LABORATORY, X-RAY & INVESTIGATION BILL
SUBTOTAL (B)
C CHEMIST BILLS
SUBTOTAL(C)
TOTAL RS. [A+B+C]
TOTAL RS. IN WORDS

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