Hospitalisation Benefit Claim Application

THE SOCIETY RESERVES THE RIGHT TO DEDUCT ALL ARREARS FOR THIS POLICY 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 CAUSE A 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 *

Email

Confirm Email

Membership Number

Phone Number *

National Insurance Number

Garage / Depot *

Current Occupation *

Employee Number

Nature of Hospitalisation / Incapacity *

Briefly describe the nature of your hospitalisation

Date Admitted to Hospital *

Date Discharged from Hospital *

Have you suffered from this condition in the last 12 months? *

Yes
No

Please give details and date(s) of the last episode(s)

The Society will not pay any sickness claim which occurs within the first 12 months of taking out the Policy which is caused by any pre-existing medical condition you may have.

Please upload admission/discharge certificate issued by the hospital :

Drop your file here or click here to upload You can upload up to 3 files.

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

DECLARATION

I declare that:

• I have read and understood the Disqualification and Forfeiture of Membership Provision of my TFS Hospitalisation Plan Terms and Conditions document.

• I declare that the above information is true and complete and I have uploaded an admission/discharge certificate issued by the hospital.

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

Hospitalisation Benefit Application Form