Make a claim Policyholder detailsName* Forename(s) Surname Policy Number* Date of birth* DD slash MM slash YYYY HiddenAddress 1 HiddenAddress 2 HiddenAddress 3 HiddenPostcode HiddenIf 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)* DD slash MM slash YYYY Relationship to you:* Receipt based claimsPlease ensure all relevant/original receipt(s) are enclosed.Treatment type* Dental Optical Chiropody Reason for treatment* Receipt Date* DD slash MM slash YYYY 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 Select files Max. file size: 50 MB. Prepare documents as electronic files in PDF or JPG format to upload from your device.Please send original documents by post to: Paycare House, George Street, Wolverhampton, WV2 4DX.HiddenPayment detailsOnly 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 detailsWe will use the address and bank details currently on file to process your claim. To check/change these details give us a call.HiddenName of bank: HiddenName of branch: HiddenAccount number: HiddenSort code: DeclarationConfirmation* 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.