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STATE BANK OF INDIA RETIRED EMPLOYEES' MEDICAL BENEFIT TRUST CLAIM FOR REIMBURSEMENT OF DOMICILIARY TREATMENT 01 Name of the employee (member pensioner) 02 Date of Retirement Membership Number 03

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10 Type and extent of hospital treatment 11 Age at start of the present illness 12 Age at commencement of next usual working life 13 Age at end of current working life 14 Total amount of Medical Expenses made in current & previous 10 12 1.0% 19.0% 10.0% 15.0% 22.0% 22.0% 11.0% 0.0% 1st year of retired life in which medical Expenses made. 3.0% 12 2.0% 12.0% 15.0% 20.0% 20.0% 6.0% 12.0% 21st year of retired life in which medical Expenses made. 4.0% 14 3.0% 16.0% 20.0% 25.0% 25.0% 10.0% 0.0% 0.0% 0.0% 3 years of retiring life in which medical Expenses made. 5.0% 15 4.0% 13.0% 19.0% 24.0% 24.0% 10.0% 0.0% 0.0% 4.0% 3 years of retiring life in which medical Expenses made. 5.0% 16 5.0% 14.0% 19.0% 24.0% 24.0% 10.0% 0.0% 0.0% 5.0% 6 years of retired life in which medical Expenses made. 6.0% 17 6.5% 13.0% 18.0% 24.0% 24.0% 10.0% 0.0% 0.0% 6.5% 7 years of retired life in which medical Expenses made. 7.0% 18 7.0% 11.0% 16.0% 19.5% 24.0% 10.0% 0.0% 0.0% 7.0% 8 years of retired life in which medical Expenses made. 8.0% 19 8.5% 12.0% 15.0% 20.5% 20.5% 10.0% 0.0% 0.0% 8.0% 9 years of retired life in which medical Expenses made. 9.5% 20 9.0% 9.0% 15.0% 19.5% 19.5% 10.0% 0.0% 0.0% 9.0% 10 years of retired life in which medical Expenses made. 10.5%

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