Private Healthcare Cashback Claim Form

expenses claim

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

A. Details
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Please enter a valid date of birth
Home address
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Email address
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Please enter a valid email address
Phone Number
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Please enter a valid UK phone number
B. Employment details
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C. Claim details
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Please enter a valid date
Please upload a document
D. Bank details
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Bank details failed to verify - please try again
E. Confirmation
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