Private healthcare cashback claim form

expenses claim
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
This field is required
This field is required
This field is required
Please enter a valid date of birth
Home address

Contact address Change address

This field is required
This field is required
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
Please enter a valid phone number
B. Employment details
This field is required
This field is required
This field is required

Contact address Change address

This field is required
This field is required
C. Claim details
This field is required
Please enter a valid date
Please upload a document
D. Bank details
This field is required
This field is required
This field is required
This field is required
Bank details failed to verify - please try again
E. Confirmation
This field is required
Please confirm you are not a robot

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