Specsavers Studentsafe Pre-approval Request Form

Policy Holder and Individual Pre Approval Request *

Student Id*:   


Course Type*:   

Multi Year/Returning Student    12 Month    Part Year/Short Course

Policy Holder*:   

please enter FULL name as per passport



Student visa expiry date:   

Date of Birth*:   


Email address*:   

Telephone number business hours*:   


Studentsafe inbound policy*:   

Education Provider*:   

Family / Couple Pre Approval Request:
Only complete this section if you have paid for family cover and your spouse or child listed on the policy require the optical benefit:


please enter FULL name as per passport


Date of Birth:   

Email address:   

Telephone number business hours:   

Appointment Details *

Specsavers Store*:   


Nature of Claim *
*Lost or Stolen Damage Change of Vision

Please provide a   
small description of   
nature of claim*:   

(If stolen include   
police report ID)   

(If damaged bring the   
damaged product   
to Specsavers for   


Find a Specsavers Store here...
For Studentsafe Optical Benefit and Privacy Notice information please refer to your policy


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