Please use this form to make a Cashback claim. We'll respond to your query as soon as possible.
Claim details
Is your claim due to an accident? *
Please select
Yes
No
Have you already completed an accident form? *
Please select
Yes
No
Only answer if you've selected
'Yes'
for
field_C01
Only answer if you've selected
'Yes'
for
field_C02
In the 'Upload documents' section below, please attach a scanned copy of the
completed accident form along with your invoice(s).
Only answer if you've selected
'No'
for
field_C02
Before you submit this form, please complete an accident form, scan it, and attach
the scanned copy of the completed accident form along with your invoice(s) in the
'Upload documents' section below.
Are you the main policyholder? *
Please select
Yes
No
Policyholder's full name: *
Only answer if you've selected
'No'
for
field_C03
What is your relation to the policyholder? *
Only answer if you've selected
'No'
for
field_C03
Your first name: *
Your last name: *
Contact telephone number: *
Your email address: *
Membership number: *
Are you the patient? *
Please select
Yes
No
Patient's full name: *
Only answer if you've selected
'No'
for
field_C11
Patient's DOB: *
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Only answer if you've selected
'No'
for
field_C11
Is the patient over 16? *
Please select
Yes
No
Only answer if you've selected
'No'
for
field_C11
Please tick that you have permission from the patient to discuss their claim with us.
If you don't have permission, you cannot proceed. Where we state 'you/your' throughout
this form, we mean the patient. *
Only answer if you've selected
'Yes'
for
field_C14
Please tick that you consent for AXA Health to process any data received in relation to
this claim. This will include any invoices and medical information. This information will
be processed to make payment and determine claim eligibility. *
Payment details
Do you want to receive payment into your account? *
Please select
Yes
No
Only answer if you've selected
'Yes'
for
field_C17
We'll use the bank account details we have unless you tell us otherwise.
If we don't hold any, we'll send a cheque.
Payments usually take 4 working days once processed. Cheques will take 7-10 working days.
Only answer if you've selected
'No'
for
field_C17
Payments by cheque usually take 7-10 working days once processed.
What is the total amount you're claiming for?
Upload documents*
Please attach your itemised invoice(s), receipt of payment, and accident form if required.
There is a 25MB upload limit
We cannot accept credit or debit card details online