ATHLETE CLAIM FORM Athlete Name * First Name Last Name Email * CLAIM DETAILS Date * MM DD YYYY Description * Invoice No/Service Provider/Brief Description/Full Invoice Amount/Claim Approved By Amount $ * PRIVATE HEALTH COVER DECLARATION Do you have Private Health Cover? * Yes No If yes, has Private Health Cover been claimed? * Yes No Private Health Cover claim amount paid: * Total Claim (Gap Payment only) * PAYMENT DETAILS Account Name: * BSB Number * Account Number * NOTE: Please attach supporting receipts/documents with your invoice | Please allow two weeks for processing of this claim Thank you for completing the claim form. If we have any questions, we will be in touch. Now you have submitted your claim form, please click below to upload your supporting receipts/documents. UPLOAD RECIEPTS
