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Submit your claim
for treatment online

You can submit your claim online by using the form below. If you’re unsure and you’d prefer to speak to someone from our claims team, give our UK-based team a call on +44 1276 486 460. You can also email claims@william-russell.com and arrange a time for us to call you. Just so you know, our office hours are Monday to Friday, 6am to 6pm (GMT).

If you have a medical emergency and you require immediate medical assistance, please contact 24 hours helpline +44 1243 621 155 provided by our assistance partner, Charles Taylor. There is a person on the other end of the phone 24 hours a day, 365 days a year.

Please complete this form if you’ve already paid for your medical treatment and you’d like to claim back the eligible costs. Please upload any supporting documents you have following your treatment (e.g., invoices, receipts). If the amount you’re claiming for exceeds US$500 (or equivalent in another currency), please ask your physician to complete section B of the PDF claim form then upload to this form.

"*" indicates required fields

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2

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5

Details of the claimant

Claimant's name*

Claimant's address*

Claimant's date of birth*

DD slash MM slash YYYY

Plan/policy number*

Customer/member ID*

Email address*

Telephone number*

Does this submission relate to a previous claim?*

No

Yes

Please provide the claim reference number for the previous claim*

Details of the condition being treated

Date you were first aware of symptoms*

DD slash MM slash YYYY

What are/were your symptoms?*

When did you first consult a physician about these symptoms?

DD slash MM slash YYYY

What is your physician's diagnosis?*

Have you ever suffered from this (or any related condition) before?*

When did you suffer from this (or the related) condition?

DD slash MM slash YYYY

Is your claim related to injuries sustained in an accident?*

No

Yes

Please provide details of the accident and injuries sustained

Details of bills for which you are seeking reimbursement

Date(s) of treatment*

DD slash MM slash YYYY

Details of the invoice / name of the treatments*

Currency and amount you paid*

Please provide any additional information about this bill

Add another bill?*

Bill 2 details

Date(s) of treatment

DD slash MM slash YYYY

Details of the invoice

Currency and amount you paid

Please provide any additional information about this bill

Add a third bill?

Bill 3 details

Date(s) of treatment

DD slash MM slash YYYY

Details of the invoice

Currency and amount you paid

Please provide any additional information about this bill

Add a fourth bill?

Bill 4 details

Date(s) of treatment

DD slash MM slash YYYY

Details of the invoice

Currency and amount you paid

Please provide any additional information about this bill

Add a fifth bill?

Bill 5 details

Date(s) of treatment

DD slash MM slash YYYY

Details of the invoice

Currency and amount you paid

Please provide any additional information about this bill

Add a sixth bill?

Bill 6 details

Date(s) of treatment

DD slash MM slash YYYY

Details of the invoice

Currency and amount you paid

Please provide any additional information about this bill

How you wish to be reimbursed

How would you like to be reimbursed?*

If you’re instructing us to pay your claim in a currency other than the currency in which you pay your premiums, we won’t be responsible for losses due to exchange rate fluctuations. If we’re making a payment for multiple invoices that you’ve submitted, we’ll use the exchange rate for the date stated on the final invoice during your policy year. If the invoices fall in two policy years, we’ll use the date stated on the final invoice during each policy year.

Currency in which you would like to be reimbursed*

If you are paying your premium by credit card do you wish to be reimbursed to the same card?*

Yes

No

Please confirm the last four digits of your credit card number*

Please complete this form and email to claims@william-russell.com.

*

I have completed the reimbursement form and have sent it via email.

Currency in which you would like to be reimbursed*

If other, please specify*

If you have you previously submitted a claim with us, do you want to receive payment to the same bank account as before?

Yes

No

Please confirm the last four digits of your bank account

Please provide the bank details of the account you wish to receive payment to below.

Bank name and address

Account holder name(s)

Bank account number

Sort code

IBAN number*

BIC number*

*BIC and IBAN details are necessary for all transfers to European and UAE bank accounts. BIC and bank account numbers are necessary for all transfers to international bank accounts.

Declaration and authorisation

Do you have any other health insurance cover?

Yes

No

Please provide the name, address, and your policy number of your other health insurance

Consent*

I declare that the information contained in this form is complete and accurate to the best of my knowledge and belief. I authorise any physician, medical doctor, health professional, or medical establishment that I have consulted, or who has treated me, to provide to William Russell and/or its authorised representative, with any and all information relating to my medical history.

If the claimant is a child under age 16, the claimant’s parent or guardian should complete this form.

If the claimant is unable to provide properly informed consent due to cognitive disability or otherwise, or if the claimant is deceased, the claimant’s next of kin should complete this form.

In either case, please state your relationship to the claimant and provide contact information.

I agree

Name of claimant*

Please upload all supporting documents*

Drop files here or

Max. file size: 10 MB.

Our privacy policy contains information about how we use your personal information, who we share it with, and your rights over how it is processed.

Name

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This website is designed to give you information on the products and services offered by William Russell, with content written by people—not AI. If you are unsure whether these products and services are suitable for you, please speak to a financial or insurance adviser. We work hard to ensure the information we provide is accurate and up-to-date, but mistakes are possible. The T&Cs that apply to your policy are those found in your plan agreement. William Russell Europe SRL is registered at Place Marcel Broodthaers 8, B-1060 Saint-Gilles, Brussels and is registered in Belgium with the Financial Services & Markets Authority (no. 0731.975.658 RPM) as a limited liability company with share capital of €30,000. William Russell Europe SRL is a mandated underwriter for AWP Health & Life SA. The UK branch of William Russell Europe SRL is registered at William Russell House, The Square, Lightwater, Surrey, GU18 5SS, UK. The UK branch is authorised & regulated by the Financial Conduct Authority (FCA), reference no. 973067. William Russell Ltd is authorised & regulated in the UK by the FCA, reference number 309314, and is registered in England & Wales under company number 02687939 at William Russell House, The Square, Lightwater, Surrey, GU18 5SS. Privacy | Legal | Other policies

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