Make a claim - Paycare

Comments

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Policyholder details

Name*

Forename(s) Surname

Policy Number*

Date of birth*

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Address 1

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Address 2

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Address 3

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Postcode

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If your name/address has changed please tell us your previous details:

Telephone*

Email*

This claim is for*

Me
My partner or dependent child

Partner / Child name*

Forename(s) Surname

Partner / Child Date of birth (DD/MM/YYYY)*

Relationship to you:*

Receipt based claims

Please ensure all relevant/original receipt(s) are enclosed.

Treatment type*

Dental
Optical
Chiropody

Reason for treatment*

Receipt Date*

Receipt value (£)*

Supporting documents*

In order for us to process your claim we need to check your supporting documents. You can either upload copies here or select to send them in the post.

Upload documents
Post documents

Upload documents

Drop files here or

Accepted file types: doc, docx, pdf, jpg, jpeg, png, Max. file size: 7 MB.

Prepare documents as electronic files in PDF or JPG format to upload from your device. Email any documents over 7MB to enquiries@paycare.org, change selection to 'post documents' and submit your claim.

Please send original documents by post to:

Paycare, The Science Centre, Wolverhampton Science Park, Glaisher Drive, Wolverhampton, WV10 9RU.

or email enquiries@paycare.org

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Payment details

Only fill in this section if you have changed your bank details or if this is your first claim to be paid directly into your bank account.

Address and payment details

We will use the address and bank details currently on file to process your claim. To check/change these details give us a call.

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Name of bank:

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Name of branch:

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Account number:

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Sort code:

Declaration

Confirmation*

I confirm that all the details given on this claim form are, to the best of my knowledge, correct. I authorise you to contact the relevant practitioner, without needing to advise me, to request further information in relation to my claim. I confirm that I cannot recover and/or have not recovered any of the costs I have incurred from any other insurer or any third party.

Terms and conditions*

I have read the terms and conditions

Don't forget!

You have 13 weeks to submit your claim from the date you paid for your treatment, or the date you were admitted to hospital.

Warning

If you attempt to make a fraudulent claim we will cancel your policy with immediate effect, and may take legal action.