Dental costs

Step 2

of 5

Tell us about you

Are you the policyholder or a group scheme member?

Yes

First name of the person who received the treatment (As it appears on your policy certificate)

Last name of the person who received the treatment (As it appears on your policy certificate)

Policy number (You can find this on your certificate and it usually consists of 3 letters and 5 digits such as GIZ12345.)

Phone

Step 3

of 5

Tell us about your treatment

What type of treatment took place? (Select one option)

Routine (e.g. Check-ups, x-rays and hygenist fees))

Accidental dental injury (Does not apply to Freedom Essentials clients)

Please tell us about your accidental dental injury; what happened, when it happened, and where it happened

When did the treatment take place? (If more than one date applies, please enter the first treatment date)

What is the total amount paid for this treatment? (in £)

Step 4

of 5

Please upload your documents

Please upload a copy of your invoice(s). (Accepted files: pdf, png, jpg, jpeg, gif, bmp, tiff)

When uploading a document:

Make sure the following details are included: name of patient, date of service, detail of service, cost of service
Ensure the whole document is visible
Please provide an itemised receipt/invoice
You can upload more than one document
Maximum size you can upload is 15 MB across all attachments

Upload document

Max size: 15 MB

Step 5

of 5

Payment method

Choose your preferred payment method (Select one option)

By Cheque (payable and sent to the policyholder's address or the employee's address for group schemes)

By BACS (sent directly in the policyholder's account or the employee's account for group schemes)

Payment Details

Please provide us with the policyholder's or group member's bank account details to facilitate the payment of the claim. If you are not the policyholder or the payment details provided are incorrect, the payment will be sent by cheque.

Full name of account holder

Sort code

Account number

Declaration

I declare to the best of my knowledge and belief that the information provided in this form is true and complete.

*Calls may be recorded and monitored for quality and training purposes.

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