Benefit Wallet Claims Form Download Form Section A - Member DetailsMember NumberDate of Birth DD MM YYYY First NameSurnameHome TelephoneCellphone NumberEmail Address Date DD MM YYYY Postal Address Street Address City State / Province / Region ZIP / Postal Code Section B - Principal Member DetailsMember NumberDate of Birth DD MM YYYY First NameSurnameRelationship to MemberDiagnosisSection C - Claims Detail (attach copies of all related claims)Health ProfessionalDate of TreatmentClaimed Amount Section D - Bank Details (For EFT Claim Refunds) (Attach proof of bank account details)Name of Account HolderBank NameBranch CodeType of AccountChequeTransmissionSavingsAccount NumberSection E - DeclarationSignatureDate DD MM YYYY Section F - For Office Use OnlyAssessor NameDate Assessed DD MM YYYY SignatureValidator NameDate Checked DD MM YYYY Signature