Payment Claims Voucher
| Pcv No | 2026-06-032958 | Settle Date | June 15, 2026 |
| Insured Name | ROOM TO READ CAMBODIA | Policy No | CHC/PPI/C-1050 |
| Claims No | CL/CHC/PPI/21274-01 | ||
| No | Invoice No | Description | Exchange Rate | Amount |
|---|---|---|---|---|
| 1 | Payment For: OUT-PATIENT | USD 21.87 | ||
| Pay To: KHIEU RAKSMEY | ||||
| Payment Status: Full Payment | ||||
| Cheque No: | ||||
| Total | USD 21.87 | |||
| Amount in Word | USD Twenty One and Eighty Seven Cents Only |
| Reviewed & Appr. PPI | Signature | Name | Date |
|---|---|---|---|
| PREPARED BY | vichet | June 15, 2026 | |
| CHECKED BY AM | KUSORL | June 15, 2026 | |
| VERIFIED BY HOD | SOCHEAN | June 15, 2026 | |
| APPR BY PPI CEO | SALY SOULEVANN | June 15, 2026 |
| Review And Approved By Group : | CHAIRMAN & CEO | CFO |
| Account Code | Account Name | Debit | Credit | |
|---|---|---|---|---|
| 111013 | Claim Paid-Medical Exp. | 21.87 | ||
| 660020 | Amount due from/(TO)Reinsuranc | 6.56 | ||
| 115513 | Claim Rec.Cam.Re- Medical Exp | 6.56 | ||
| Claim Rec.Out FAC-Medical | ||||
| Claim Rec.Q.T Share-Medical | ||||
| 660216 | ABA - Collection Acct | 21.87 | ||
| TOTAL | 28.43 | 28.43 | ||
Print By: vichet