The Human Resources Manager,
________ (Company Name),
________ (Address)

Date: __/__/____ (Date)

Subject: Delayed submitting documents for mediclaim

Respected Sir/Madam,

My name is __________ (Name) and I do hold an _______ (corporate insurance policy/company insurance scheme) under ___________ (Scheme) having policy number _______ (Policy number). I am a resident of _________ (Residence).

I am writing this letter to request you for reimbursing the mediclaim for ________ (hospital/medicine) bill reimbursement. Respected, due to the reason ___________ (Reason- bed rest/ hospitalized/ not well/ out of time) the documents were not submitted in time. I beg apology for the same. I request you to kindly consider this application as genuine and help me by providing me with the reimbursement for the bill attached herewith.

I shall be highly obliged if the same would be approved at the earliest.

The details for my claim are mentioned below:
Name: ___________
Amount: ___________
Claimed amount: ___________
Reason: ___________

I declare that the provided information is true and do take responsibility for the medical requested.

Thanking you,
___________ (Signature),
___________ (Name),
___________ (Address),
___________ (Contact Number)

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