Dental Claim Form printable pdf download

Claim form

Fill in your personal details below.

Ask your dentist or the receptionist to complete the back of this form and attach a receipt for the full

cost of treatment. If you’re unable to have the reverse page completed at the dentist, please obtain

an itemised receipt and attach it to your claim form.

email, online or post

Submit your claim to us by

using the details below:

Please note:

dentalclaims@unum.co.uk

email:

Claims must be

submitted within 90 days

online:

of completion of your last

Unum Dental, Milton Court, Dorking, Surrey RH4 3LZ

post:

treatment in any course.

020 7488 9880

tel:

(calls may be recorded for training and monitoring purposes)

Reimbursement will be

made according to

We can only process claim forms that are accompanied by full proof of payment.

your benefit schedule.

You complete this section

Mr Mrs Miss Dr Other:

Date of birth:

Full name:

Home address:

Postcode:

Telephone number:

Name of employer:

Membership number (if known):

Patient details (if different from above):

Mr Mrs Miss Dr Other:

Date of birth:

Full name:

Declaration

- to be signed by patient (or by member if patient is under 18 years of age)

I declare that the information provided on this form is, to the best of my knowledge, true and complete and authorise Unum Dental to obtain any information

relating to this claim from my dentist. I confirm that I give consent within the provisions of the Data Protection Act 1998 for Unum Dental and/or its agents to process

my personal data, including medical information, for the purposes of administering the dental plan.

Date:

Signed:

If you wish to receive payment by cheque, please tick here:

If you wish to receive payment by BACS, please tick here:

then complete the details below

Account name:

Account number:

Sort code:

Roll number (if applicable):

Email address for remittance advice:

Please remember to attach your receipt when sending your claim to Unum Dental