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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 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.
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.
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.