Refund Request Form

IMPORTANT NOTE: Please complete the entire form for your refund to be processed. Please submit online or email the completed form as well as your supporting documentation to refunds@kaelo.co.za. Your refund will be processed within 14 days of receipt of all the information. Where no proof of bank details have been supplied, Prime Cure will not be held responsible for any payment made into an incorrect account.

Details of Principal Member / Policyholder

Surname *

First Name *

Email *

Member / Policy Number *

Telephone

Fax

Medical Scheme / Health Insurer *

Medical Scheme Plan / Option

Cell *

Identity Number / Passport *

Gender

Male

Female

Age

Banking Details

The bank account holder must be the same person for whom supporting documentation is submitted.

Account Holder *

Bank Name *

Account Number *

Branch Name *

Branch Code *

Account Type *

Cheque

Savings

Transmission

Signature *

Clear

Supporting Documentation

The following documents are required for your refund request to be processed. Your refund will be processed within 14 days of receipt of all the information.

A copy of your ID *

Maximum file size: 2MB

A copy of the account you received from the provider that supports your refund claim. *

Maximum file size: 2MB

Your receipt from the provider that shows proof of payment. *

Maximum file size: 2MB

Any requests over R3000 must be accompanied by proof of banking details (such as a bank stamped statement or letter).

Maximum file size: 2MB

CAPTCHA

If you are human, leave this field blank.

OR Download Offline Form