FOR OFFICE USE ONLY

Eligibility Date:
Last Contribution:

Healthcare Reimbursement Form

Amount Paid:

Please remove all staples from documents and paperclip together.

Eftpos receipts are not required if the credit is already shown on the tax invoice.
Please complete ALL sections of this form (and refer to the checklist on the reverse).
Once completed please post to: Marram Community Trust. PO Box 24006, Manners Street ,Wellington 6142.

Name of current employer:

Employee No:

First Name
Last Name:
Email:
Work Phone: [0

]
]

Home Phone: [0

Fax: [0

Mobile: [0

Postal Address:
Suburb:

City:

Do you want your partner/spouse to make enquiries on your behalf?

Yes

No

DETAILS OF THE ACCOUNT TO BE CREDITED

Bank

Branch

Account Number

Suffix

All claims will be paid as direct credits, no cheque or cash payments will be made.
Marram accepts no responsibility for the bank account details you have provided.

Do you have medical insurance? Yes

No

Name of Insurer:

Policy type:

For assistance see reverse

Type of expenses being claimed: Please tick

GP

Healthcare Grant

Prescriptions

Surgical

Physiotherapy

Alternative Therapists

Other. Please specify

Specialist. Please provide details of treatment

Optical Are you covered by a Health and Safety Agreement for computer use at work? Yes
Please claim from your company in the first instance

These expenses are for:

Full Name

* Status: SP = Spouse P= Partner

DC= Dependent Child



To the best of my knowledge, the details
I have provided are true and correct.

No

Date of Birth

Please check reverse for definition details

Signed:

Date:

Status*

CHECK LIST

READ THIS BEFORE YOU POST YOUR CLAIM

Accounts and receipts must be originals or certified copies (not photocopies).

Accounts and receipts must show full payment.

All staples have been removed from the receipts.

Accounts and receipts must be lodged within 12 months of the treatment provided.

Accounts and receipts must show clearly who received the treatment.

Accounts and receipts must show what the treatment was and the date the service was received.

You must supply your own bank account details.

You must sign the form.

Receipts and treatment are for after your three month stand-down period (if applicable)

Special conditions apply to some benefits and the circumstances under which they are reimbursed.
For the full range of Marram Healthcare benefits, please go to our website: www.marram.co.nz , contact
Customer Services on 04 801 2920 or email enquiries@marram.co.nz
Remember if you have Medical Insurance:

Lodge your claim with your insurance company first.

Request that your insurance company returns originals or certifed copies of your invoices and receipts.

Include the remittance advice from your Insurer detailing any payments received.

*Status definitions
SP =Spouse:
P

Husband or Wife

=Partner:

DC =Dependent Child

A person residing with you in a de facto relationship for at least 12 months.

You or your partners dependent child up to their 18th birthday.

Marram Community Trust. Republic2, 10 Lorne Street, Te Aro, Wellington. PO Box 24006 Manners Street Wellington 6142
Phone: (04) 801 2920 Facsimile: (04) 385 3558 E-mail: enquiries@marram.co.nz Website: www.marram.co.nz