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
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Please enter a valid date of birth
Home address

Contact address Change address

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Email address
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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
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Contact address Change address

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C. Claim details
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This is the date on the documentation requesting payment for the excess.
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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Need help? Call: 01189 341 808 (9am-5pm)