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Claim Reimbursement

 

This form can be completed if you have paid for treatment and would like to claim back the eligible costs

If the amount of your claim exceeds US$500 (or equivalent in another currency) please ask your physician to complete section B of the claim form which can be found here. This will then need to be uploaded with this form or emailed to us later at claims@william-russell.com

Your Personal Details

Please complete the information requested and include supporting information via the document upload function

Claimants name  
Claimants address  
Date of birth  
Policy Number/Plan Number  
Email Address  
Telephone number  



Details of the condition being treated
Date you were first aware of symptoms  
When did you first consult a physician about these symptoms
What is your physician's diagnosis?  
Have you ever suffered from this or any related condition before?
                
Is your claim related to injuries sustained in an accident?