receipt header image
FOR OFFICE USE ONLY
PLEASE REFER TO YOUR MEMBERSHIP PLAN WHEN CLAIMING BENEFITS.
PLEASE MAKE SURE YOU COMPLETE YOUR MEMBER NUMBER AS YOUR CLAIM COULD BE DELAYED.
1 MEMBER'S PERSONAL INFORMATION
TITLE
SURNAME
FORENAME(S)
DATE OF BIRTH   (DD/MM/YY)    MEMBER NUMBER  
FULL POSTAL ADDRESS (INCLUDE POST CODE)
CONTACT EMAIL ADDRESS
CONTACT TELEPHONE NUMBER
EMPLOYMENT COMPANY DETAILS (IF APPLICABLE)
PAY OR EMPLOYEE NUMBER (IF APPLICABLE)
2 RECEIPT BASED CLAIMS A SAMPLE RECEIPT IS SHOWN AT THE BOTTOM OF THIS FORM
please ensure that you enclose all the relevant, original receipts with this claim form. If you have had a series of treatments the receipt must show the date and cost for each treatment.
I AM CLAIMING FOR:
you partner child date of birth benefit amount paid date of treatment medical reason for
treatment
IF APPLICABLE, I ENCLOSE A COPY OF MY NEWBORN BABY´S
FULL BIRTH CERTIFICATE
For dental accident claims please also see section 4
3 METHOD OF BENEFIT PAYMENT
HOW DO YOU WISH THIS PAYMENT TO BE MADE? CHEQUE SEE(A)  EXPRESS DIRECT CREDIT SEE(B) 
(A) CHEQUES TO BE MADE PAYABLE TO
(IF DIFFERENT FROM THE MEMBER)
PLEASE TICK IF YOU DON'T WISH YOUR DIRECT CREDIT NOTIFICATION TO BE SENT BY EMAIL  
TITLE 
SURNAME 
FORENAME(S) 
(B) COMPLETE THIS SECTION TO BE PAID BY DIRECT CREDIT (IF YOU HAVE ALREADY PROVIDED THESE DETAILS THEN THERE IS NO NEED TO FILL THEM IN AGAIN UNLESS YOUR ACCOUNT DETAILS HAVE ALTERED)
BANK/BUILDING SOCIETY NAME ACCOUNT NUMBER SORT CODE
--
4 FOR DENTAL ACCIDENT CLAIMS ONLY (THIS SECTION MUST BE COMPLETED BY YOUR DENTIST)
DATE OF ACCIDENT CAUSE OF ACCIDENTOFFICIAL STAMP OF DENTIST
(DD/MM/YY) 
Please enclose the receipt from the dentist confirming the treatment has been caused by a direct blow to the head
PATIENT´S NAME
 
SIGNATURE OF DENTIST
5 MEMBER´S AUTHORISATION AND SIGNATURE
I GIVE MY CONSENT TO ALL PROCESSING OF PERSONAL AND SENSITIVE DATA. I DECLARE THAT ALL THE INFORMATION INCLUDED IS ACCURATE, TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE AND BELIEF. I AGREE THAT HEALTH SHIELD CAN CONFIRM THE DETAILS WITH THE HEALTHCARE PROVIDER. I UNDERSTAND THAT HEALTH SHIELD MAY END MY MEMBERSHIP IF MY CLAIM IS FOUND TO BE FRAUDULENT.
DATE
(DD/MM/YY) 
YOUR SIGNATURE
FRAUDULENT CLAIMS: HEALTH SHIELD ARE COMMITTED TO PREVENTING FINANCIAL CRIME AND WE WILL REPORT TO THE POLICE ALL INSTANCES OF FRAUD OR ATTEMPTED FRAUD.
CLAIMS CHECKLIST
HAVE YOU SIGNED AND DATED SECTION 5?
HAVE YOU ATTACHED THE RELEVANT RECEIPTS, CERTIFICATES OR PAPERS ?
HAVE YOU INCLUDED YOUR MEMBERSHIP NUMBER ?
HAVE YOU COMPLETED SECTION 3?
 
PLEASE RETURN TO SAMPLE RECEIPT FOR GUIDANCE
PLEASE RETURN THIS FORM, ALONG WITH ALL NECESSARY ADDITIONAL INFORMATION AND RECEIPTS TO HEALTH SHIELD. WE AIM TO TURNAROUND ALL RECEIPT BASED CLAIMS WITHIN TWO WORKING DAYS. sample receipt for guidance

Health Shield Friendly Society Ltd
Electra Way, Crewe Business Park,
Crewe, Cheshire CW1 6HS

Investor in People Health Shield Friendly Society Ltd. Electra Way, Crewe Business Park, Crewe, Cheshire, CW1 6HS
Telephone: 01270 588555 Fax: 01270 251366 Opening hours: 8.00am to 6.00pm, Monday to Friday
Email: info@healthshield.co.uk Website: www.healthshield.co.uk Established in 1877.
Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority.
As part of our on-going quality control programme, calls may be monitored or recorded.


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PLEASE REFER TO YOUR MEMBERSHIP PLAN WHEN CLAIMING BENEFITS.
PLEASE MAKE SURE YOU COMPLETE YOUR MEMBER NUMBER AS YOUR CLAIM COULD BE DELAYED.
TICK AND/OR COMPLETE THE APPROPRIATE BOXES WHERE APPLICABLE PLEASE PRINT THIS FORM AT 100% SCALE ON YOUR PRINTER SETTINGS SO IT PRINTS OVER 2 PAGES