Credit Card Reimbursement Form
Please complete this form in BLOCK CAPITALS using black ink, and email to [email protected]. You will need to complete
a new form each time you submit a claim.
Your personal details
Full name: .. ............................................................................................................................................................................................................................................................
Policy number (if applicable): ......................................................................... Email: ..........................................................................................................................
Mobile number: ..................................................................................................... Home number: .......................................................................................................
Credit card details
I would like the reimbursement for my claim to be paid to the following credit card:
Please note we can only make payment to a VISA card or a MASTERCARD card. Settlement can be provided in US dollars,
pounds sterling or Euros.
Currency in which you would like to be reimbursed: US dollars Pounds sterling Euros
Card number: ...................................................................................................... Start date: ..................................... Expiry date:............................................
Name as it appears on your card: . . ............................................................................................................................................................................................................
Address to which your card is registered: .............................................................................................................................................................................................
....................................................................................................................................................................................................................................................................................
Name of claimant: ...........................................................................................................................................................................................................................................
Signature of claimant: ................................................................................................................................................................. Date .................................................
Contact Details William Russell Europe SRL William Russell Ltd
T +44 1276 486 460 Place Marcel Broodthaers, 8 William Russell House, The Square
E
[email protected] B-1060 Saint-Gilles Lightwater, Surrey, GU18 5SS
william-russell.com Brussels UK
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 by the Financial Conduct Authority. Reference number 309314. Registered in England & Wales, company registration number
02687939.
17 December 2024 | v5 1
