Your personal details

William Russell Ltd is authorised & regulated in the UK by the Financial Conduct Authority, ref. number 309314. Registered in England and Wales, reg. number 02687939. 
Registered address: William Russell Ltd, William Russell House, The Square, Lightwater, Surrey, GU18 5SS.

© William Russell Ltd, 2020    |    Privacy

Pre-Authorisation Request

Please provide as much detail as possible. You must complete all fields with an asterisk (*). To submit your pre-authorisation request, just click the submit button at the end of the form. You will receive a confirmation email, and a member of our claims team will contact you within 24 working hours. If you need urgent medical treatment, please see our emergency contact details.

Please complete the form and send supporting information via email to claims@william-russell.com

Your physician details

Details of the condition/symptoms

Clinical information

Insurer information

*This form should be completed by the claimant’s parent or guardian if the claimant is a child under age 16, or by the claimant’s next of kin if the claimant is unable to provide properly informed consent due to cognitive disability or otherwise, or if the claimant is deceased. Please also state your relationship to the claimant and provide contact information.

*Our privacy policy contains information about how we use your personal information, who we share it with and your rights over how it is processed. For full details of our privacy policy, please visit www.william-russell.com/privacy/