Reimbursement Form

Refer your CLAIMYEXCESS Confirmation of Cover (CoC) for details to be filled (as below):

Confirmation of Cover (CoC) Number

Your mobile

CLAIMYEXCESS Cover taken for

Excess amount

Start Date

Benefit Date

(Please attach Claim form lodged with your lead/main Insurance Company supported with the Proof of Excess deduction made) Or mail us at claims@claimyexcess.com with your CoC no.

If your reimbursement Case is accepted and there are payment(s) to you, we can pay direct into your bank account:

Name of Account

I/we authorise payment to be made into this bank account

Bank Code

Branch Code

Account No.

Suffix

Declaration/Privacy Act 1993/Insurance Claim register/Assignment
I/We declare that to the best of my knowledge and belief the above particulars are complete and true.
I/We
a) Agree to give any more information as desired by CLAIMYEXCESS;
b) Understand that you need this personal information to evaluate my/our reimbursement case;
c) Authorise the disclosure of this personal information to other parties;
d) Authorise you accessing/obtaining of my/our information from any other party and
Insurance Claims Register that is in your view relevant;
e) Assign you the 1st right to recover the reimbursement with regard to the claim from your main/lead Insurance
Company/third party responsible;
f) I have read through the Product Disclosure, T&C's and Privacy policy of CLAIMYEXCESS;
g) Failure to provide collection of information under the terms and conditions may result in my/our reimbursment being declined.

I have read and agreed to the terms and conditions

Reimbursement Form

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