My Staff Shop

Category 3 Claim

If you need any help or have any queries please do not hesitate to contact us on 0330 0242 280 or email customerservices@myhealthxtras.co.uk

If you have not heard back from us within 2 working days please contact customerservices@myhealthxtras.co.uk

Title*

Full Name*

Email Address*

Date of Birth (DD-MM-YYYY)

Postcode

Claimant information

Claimant Name (Leave blank if same as above)

Date of Claim (DD-MM-YYYY)*

For payment of your claim, please complete the below

Account Name*

Sort Code*

Account Number*

Select your claim type (select one)

Claim Type*

More details of above (if required)

Claim details

How much did you pay? (Leave blank if claiming for NHS Outpatient)

Date on receipt (DD-MM-YYYY)

Upload your receipt/evidence

Declaration

"I confirm that the information shown on this form and any accompanying documentation is true and correct. If submitting any information on behalf of another person covered by my policy, I confirm that I am doing so with their knowledge and permission."

Agree to e-sign this claim form *

Agree
Disagree

If you have any further evidence to submit that cannot be attached please email it to customerservices@myhealthxtras.co.uk