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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
 
Email
Your mobile
CLAIMYEXCESS Cover taken for
Claimed Amount(Minimum of "Cover Amount" & Excess Deducted by Insurer)
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.co.nz 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.