Discretionary Claim Application

Discretionary Benefit Claim Application Form

The Society reserves the right to deduct any outstanding arrears OR may decline benefits in case
of significant arrears.

Dental, Optical and Osteopathic benefits are at the discretion of the Board of Management and may be taken away at any time.

Title *

Mr
Mrs
Miss
Ms

First Name *

Last Name *

Address *

Address Line 1

Address Line 2

City / Town

Post Code

Email Address *

Confirm Email

Membership Number

Phone Number *

National Insurance Number

Discretionary Benefit Type *

Dental
Optical
Osteopathic

Claimant *

Member
Spouse

Benefits in respect of spouses and civil partners are only applicable to members who joined the Society prior to 1996.

Claim Amount *

Nature of Treatment / Service *

Upload your receipts: *

Drop your file here or click here to upload You can upload up to 2 files.

Please make sure that your receipts show your full name, practitioner's details, proof of payment and date. Debit/credit card receipts are not accepted without an official receipt. See our Receipts Requirements for full details.

Payment is made directly into your Bank Account. Please provide details below:

Account Holder's Name *

Sort Code *

Account Number *

If this is your first time of claiming, please ensure you provide verification of your bank account details such as a copy of your bank statement or a screenshot showing your name and account details.

Bank Details Verification

Drop your file here or click here to upload

Useful Checklist

Do the receipts show your full name? (credit or debit card receipts will NOT be accepted) *

Do the receipts show your full name? (credit or debit card receipts will NOT be accepted)

Do the receipts show the treatments or services provided? *

Do the receipts show the treatments or services provided?

Do the receipts show proof that payment has been made in full? (invoices will NOT be accepted) *

Do the receipts show proof that payment has been made in full? (invoices will NOT be accepted)

CONSENT

Consent *

I consent to the Transport Friendly Society undertaking any enquiries they consider necessary concerning this claim and I authorise the release of any information to the Transport Friendly Society Limited.

DECLARATION

I declare that:

• I have read and understood the Fraud Provision.

• The information I have provided on this claim form is true, accurate and complete.

• I am aware that if any of the information I have provided is not true, accurate or correct this may affect the Society’s decision to provide cover for me and may lead the Society to void my policy, reject any claim and even terminate my membership.

The Transport Friendly Society may also use this information for the operation of my insurance and to process my claim. I am aware that my data will be processed fairly and securely in accordance with current legislation and will only be available to those who need to see it.

Declaration *

I confirm I have read and understood the declaration above

Discretionary Benefit Application Form

Discretionary Benefit Claim Application Form

Useful Checklist