WHA Healthcare Claim Payment Form

FormType (Q1)
Claim Payment Form

To pay your claim directly to your bank account.
As part of our commitment to providing a seamless service, we are pleased to offer payments directly into your bank account.

Please let us know how you are currently paying your premium and then follow the steps below.
How do you pay your premium?

Direct DebitEmployer / payroll deductionCash/Cheque
Policy Number (please leave blank if unknown)
Your Details
Title *
First Name*
Surname*
Date of Birth*
Full Address and Postcode *

Address Line 1

Address Line 2

City

Postal Code
Mobile *
Please enter a valid phone number.
Tel *
Please enter a valid phone number.
Email Address*

Confirmation Emailexample@example.com
Please select your preferred choice below to stay updated about our products, services, and the latest news.

By EmailBy TextBy PhoneBy Post
Your Bank Account Details

Please provide us with the account you would like your claim to be paid to.
Full Name of your Bank or Building Society*
Full Postal Address of your Bank or Building Society

Address Line 1

Address Line 2

City

Postal Code
Name of Account Holder*
Bank Account Number *
Sort Code *
Your Consent
Should be Empty:

Claim Payment Form