Private healthcare cashback claim form

Please make sure you have read a copy of the scheme rules before applying for the cashback

A. Details

First name*

This field is required

Surname*

This field is required

Employee Number / ID*

This field is required

Date of Birth*

DD MM YYYY

Please enter a valid date of birth

Home address

Start typing your address Enter address manually

Contact address Change address

Address line 1*

This field is required

Address line 2

Town*

County

Postcode*

This field is required

Email address

Email address*

This field is required

Please enter a valid email address

This type of email address is internal to LBG and cannot be used externally. Please provide an external email address.

Phone Number

Phone number*

Please enter a valid phone number

B. Employment details

Employer*

This field is required

Workplace address*

This field is required

Grade*

This field is required

Start typing your address Enter address manually

Contact address Change address

Address line 1*

This field is required

Address line 2

Town*

County

Postcode*

This field is required

C. Claim details

Private healthcare provider (e.g. Bupa)*

This field is required

Excess payment date*

DD MM YYYY

Please enter a valid date

Please attach proof of payment from the healthcare provider (not the treatment provider)*

Uploads are limited to six files at 16Mb each.

Upload your document here

Please upload a document

D. Bank details

Please provide the bank details into which you’d like your rebate paid once it’s been approved

Name of account holder(s)*

This field is required

Name of bank/building society*

This field is required

Bank/building society account number*

This field is required

Branch sort code*

This field is required

Bank details failed to verify - please try again

E. Confirmation

I have read the terms and conditions of the Private Healthcare Cashback Scheme and I’m eligible to claim

This field is required

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