Name of bank:
Name of branch:
Account Number:
Sort Code:
Please fill in this section if the claim is for your partner or dependent child.
Surname: (Mr/Mrs/Miss/Ms)
Partner/Child Forename(s):
Date of birth: (DD/MM/YYYY)
If your name/address has changed please tell us your previous details:
Telephone: Email:
Date of birth: (DD/MM/YYY)
Relationship to you:
Partner/Child Surname:
Policy Number:
See overleaf for guidance on how to fill in this form.
Dental: Optical: Chiropody:
Type of treatment(s):
Other (please state):
Reason for treatment:
Receipt(s) total:
Date of birth: (DD/MM/YYY)Child’s Name:
Day Case
Admitted on:
Discharged on: Home leave:
Patient’s full name: Hospital Number:
Number of nights:
Name of parent:
Reason for admission/Treatment:
Hospital Stamp:
Signature of
authorised official:
Position of authorised official:
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.
Please return completed form and enclosures to:
Paycare House, George Stree
t, Wolverhampton WV2 4DX
Date received:
Claim Ref:
re ma
y conta
ct you f
rom t
e to time about products and services we think
you may be interested in, please tick here if you do not wish to receive this
For office
use only:
F. D
D. New Child Payment
ayment Details
A. Policyholder details
Paycare Claim Form
B. Receipt Based Claims
C. Hospital Claims
This will enable us to pay your claims directly into your bank account
To be completed by your hospital. Please print in BLOCK CAPITALS
Please ensure all relevant/original receipt(s) are enclosed.
Receipt(s) dated:
Parental Stay (if applicable):
Everyday Health Cover since 1874
How to fill in this form
Make sure you (the policyholder) fill in all your details. If the claim is for your partner or
dependent child covered by the policy, add their details in this section too.
If the claim is for reimbursement of costs paid by you, complete this section and send us the
original receipt(s) along with this form. Check your receipt(s) have all the relevant information:
If the claim is for Hospital Benefit, ask your hospital to complete all of this section. Or, if all
this information is on your original discharge note, you can send us that instead.
Congratulations! Complete all of this section, and send us the original full birth
certificate or adpotion papers. Well send these back to you when we’ve finished.
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.
Make sure you sign and date your form, and send your form and evidence to us at the
address at the bottom of the page.
For full terms and conditions please refer to your policy booklet or visit our website.If your policy
includes Personal Accident cover and you need to claim,please contact us to obtain a special
Claim Form. You must do this as soon as possible, but always within 30 days of the accident.
Don’t forget! Warning
You have 13 weeks to submit your claim
from the date you paid for your treatment,
or the date you were admitted to hospital.
If you attempt to make a fraudulent claim
we will cancel your policy with immediate
eect, and may take legal action.
Section A
Section B
(if you’re claiming with a receipt)
Section C (if you’ve been to hospital)
Section D (if you’ve had a new child)
Section E (bank details)
Section F
Name of person receiving the treatment
Description of treatment/service
Address of person receiving treatment
Amount paid
Name, address & qualification
of practitioner
Date paid
Date of treatment/service
Paycare is a not for profit company limited by guarantee. Authorised by the Prudential Regulation Authority and regulated by the Financial
Conduct Authority and Prudential Regulation Authority. Company Registration Number 820791.
01902 371 000