Health Cash Plan Claim Application

Personal Details
Employment Details
Claim Details
Bank Account Details
Consent & Declaration

THE SOCIETY RESERVES THE RIGHT TO DEDUCT ALL ARREARS ON THIS POLICY FROM ANY BENEFITS PAYABLE OR MAY DECLINE COVER IN CASE OF SIGNIFICANT ARREARS.

PLEASE ENSURE THAT YOU COMPLETE ALL THE INFORMATION BELOW ACCURATELY AS FAILURE TO DO SO MAY LEAD TO THE REJECTION OR DELAY TO THE PAYMENT OF YOUR CLAIM.

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

Garage / Depot *

Current Occupation *

Employee Number

Claiming For (Claimant) *

Member
Partner
Child

Name of Claimant *

Benefit Type *

For Hospital & Birth/Adoption of a Child claims you will need to complete a paper version of the claim form.

Treatment

Amount Paid (£) *

Additional Comments

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, date, details of the treatment/purchase and amount paid. Debit/credit card receipts are not accepted without an official receipt.

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

Please be aware that failure to comply with these requirements may cause a delay to the payment of your claim

Attach copies of the original, official receipts, which are not more than 12 months old. See the full receipt requirements here. Do your receipts show the following:

Do the receipts show the following? *
The full name and title of the patient
The full name, contact details and official stamp of the practitioner
Details of the treatment provided including the date
Evidence 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 of my TFS Health Cash Plan Claims Booklet.

• I declare that the above information 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 of me and may lead the Society to void my Policy/Policies, 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

Health Cash Plan Benefit Application Form

Useful Checklist