Medical Treatment / Insurance Details (*) = required fields.
  Benefit from Date Date of Birth
(DD/MM/YYYY) 		Benefit to Date Date of Birth
(DD/MM/YYYY)
  Medical / Insurance Type BUPA Memo
  Particulars Amount
  Annual premium amount for the treatment / insurance I1
  Do you want to prorate the annual premium amount paid ? I2
  Pro-rated annual premium for treatment / insurance for the tax year I3
  Amount made good by employee or amount subjected to tax I4
  Total Cash Equivalent Amount ( I3 minus I4 ) I