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. We’ll 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
eect, and may take legal action.
(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)
Name of person receiving the treatment
Description of treatment/service
Address of person receiving treatment
Name, address & qualiﬁcation
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 www.paycare.org