Private healthcare cashback claim form

Please read the scheme rules and check you’re eligible before completing this form. If you’re unsure whether you meet the eligibility criteria, please call our membership team on 0118 934 1808.

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

This field is required

Please confirm you are not a robot

Need help? Call: 01189 341 808 (9am-5pm)