Your Personal Details

First name*

Surname*

Address*

Telephone number

Mobile phone number

Claim Details

Hospital Stay Benefit
To claim for a hospital stay, please upload a copy of your discharge letter.

Date (s) of hospital stay:

Date From*

Date To*

Reason for admission to hospital*

Copy of Hospital discharge letter

Payment Details

Payment will be made directly into the bank account details we hold on record for you below. If the section is blank please provide details of the bank account you wish to receive payment.

Account number*

Sort code*

Claimant declaration and consent

I declare that I am not claiming for this claim under another health insurance product
I understand that any fraudulent claims may result in legal action being taken and immediate cancellation of my policy
I consent to ASFS processing any health and medical information contained in this form in order to pay my claim
I authorise any medical practitioner or other person(s) concerned with providing healthcare to give you any information relevant to this claim
I declare the information shown on this form and any accompanying documentation is true and complete

Digital signature: Please type your full name into this box

Privacy Notice

Anglo-Saxons Friendly Society Ltd acts as the data controller in respect of your personal data. We take your privacy seriously and we will receive, process and store data, including your personal data, to enable us to provide you with the services that we offer and for all other purposes consistent with the proper performance of our operations. For our full statement on data protection and privacy, click on ‘Privacy Policy’ at the bottom of the page.

Email verification

To complete your claims submission:

Press the green verification code button below
We will send a verification code to the email address used on this claim form
If the email address is incorrect or blank please contact our membership support team on 01474 567050 or email us at info@anglo-saxons.co.uk and we will update your membership contact details.
Copy and paste or key in the verification code from the email into the verification code box below and press submit.

Verify Code (required)