24Petwatch Claim Form – Fill Out and Use This PDF

The 24PetWatch Claim Form serves as a crucial document for pet owners enrolled in the 24PetWatch Pet Insurance Programs, designed to facilitate the submission of insurance claims for pet healthcare. It mandates the inclusion of a detailed invoice for the services claimed, alongside the pet’s complete medical history, with specific sections to be filled by both the policyholder and the attending veterinarian. To ensure a claim is processed effectively, the form underscores the importance of thoroughly reviewing policy documents to ascertain coverage eligibility for the claimed condition. For a seamless claim submission process, click the button below to fill out your form.

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24Petwatch Claim Form PDF Details

The 24PetWatch Claim Form serves as a crucial document for pet owners insured under the 24PetWatch Pet Insurance Programs, ensuring they can file claims for their pets' medical treatments accurately and promptly. Designed to be comprehensive and user-friendly, it requires detailed information from both the policyholder and the attending veterinarian to process a claim effectively. It's imperative for policyholders to include their insurance policy number and ensure that all sections (A to E) are thoroughly completed to facilitate a smooth review. The form mandates the attachment of itemized paid invoices along with the pet’s complete medical history to substantiate the claim. Furthermore, the form encompasses a section dedicated to incidents leading to a pet's death, including the necessity for euthanasia and any burial or cremation expenses. It's critical for policyholders and veterinarians to acknowledge the importance of accurate and honest disclosure of all requested details not only to comply with the program's terms but also to adhere to legal standards that vary by state, which highlight the severe ramifications of submitting false or fraudulent claims. This document, therefore, not only serves as a means to seek financial reimbursement for veterinary expenses but also acts as a legal declaration of the veracity of the claim being made.

Question	Answer
Form Name	24Petwatch Claim Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	24petwatch claim form, 24petwatch insurance claim form printable, 24 petwatchi insurance claims, pets best claim form

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2 4 P E T W A T C H C L A I M F O R M

PET INSURANCE PROGRAMS

www.24PetWatch.com • 1-866-597-2424

CHECKLIST

NOTE: You must submit an itemized paid invoice with claim form.

Make sure your Policy Number is illed in.

Review your Policy Documents and Terms and Conditions to see if coverage is available for the current condition being claimed.

You complete both Sections A and E fully.

Have your veterinarian complete Sections B-D.

Attach your detailed paid invoices for condition(s) being claimed.

Attach your pet’s complete medical history.

Please return the completed claim form with paid invoices and complete medical history to:

24PetWatch Pet Insurance Programs, P.O. Box 2150 Bufalo, NY 14240-2150 • FAX 1-866-369-7387

Need more claims forms? Download forms at: www.24PetWatch.com

A. MUST BE COMPLETED BY THE POLICYHOLDER

YOUR POLICY

YOUR PET DETAILS

Insurance Policy Number:

Pet Name:

PLEASE INCLUDE THIS NUMBER ON ALL DOCUMENTS

Pet DOB

Gender:

Male:

Female

(MM/DD/YY

Policy Type: (ie. Standard, Select, Elite)

Type of Pet:

Dog

Cat

Breed:

YOUR DETAILS

Owner Name:

Veterinarian/Clinic Name:

Address:

Indicate here if this is a new address

Phone:

Fax:

Phone:

E-mail:

B. TREATMENT INFORMATION

SECTIONS B - D MUST BE COMPLETED BY THE VETERINARY CLINIC

Treatment

Diagnosis and Treatment Details

Date Signs and

Total Treatment

Has the pet been

Is there likely

Information

Symptoms First

Cost

treated for this

to be ongoing

Noted (MM/DD/YY)

condition before?

treatment?

Yes

Medical Claim 1

If Yes, when?

(DD/MM/YY)

Yes

Medical Claim 2

If Yes, when?

(DD/MM/YY)

Has this pet had an annual physical examination in the past 12 months, and up to date on all recommended vaccinations?

Yes

How long has this pet been a patient of your clinic?

Less than 12 months

More than 12 months

If this pet was referred to you, give the name of the referring practice/clinic:

Pet’s Weight: _____

Lbs

Body Condition Score (BCS): _____

1-5 Scale (1 = emaciated, 5 = Obese)

1-9 Scale (1 = emaciated, 9 = Obese)

1127 ed 01 2013

PLEASE ENSURE BOTH SIDES OF THIS CLAIM FORM ARE COMPLETED AND RETURNED WITH RELEVANT PAID INVOICES.

C. IN THE EVENT OF DEATH

1. Date of death (DD/MM/YY)	2. Cause of death

3. If euthanasia please indicate why necessary
3. If euthanasia please indicate why necessary

4. Were there any charges made for cremation or burial?		yes	no	If so, how much? $
4. Were there any charges made for cremation or burial?		yes	no	If so, how much? $

D. VETERINARY DECLARATION		CLINIC STAMP
		CLINIC STAMP
I certify that the details above are accurate, complete and true in every respect.
Signature of veterinarian:
_______________________________________________________________________
Print Name	Date (DD/MM/YY)

E. POLICY HOLDER DECLARATION

I declare that my veterinarian recommended the treatment for which I am claiming. The veterinary clinic has completed sections B-D and the particulars given are correct to the best of my knowledge and belief. I agree that my veterinarian may provide any information that the company may require to verify my claim.

I understand that any misrepresentation or omission of any material fact can result in denial of the claim.

My total claim submitted is $

Signed (policy holder) _____________________________________________________

Date (DD/MM/YY)

If you are claiming for the death beneit, please include a receipt for the purchase price of your pet.

If you are claiming for Boarding Kennel Fees, Trip Cancellation or Lost Pet Recovery Costs (where applicable) , please refer to policy Terms and Conditions for speciics regarding claim submission.

Applicable in Arizona

For your protection, Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

Applicable in Arkansas, District Of Columbia, Kentucky, Louisiana, Maine, Michigan, New Jersey, New Mexico, Pennsylvania, Tennessee, Virginia and West Virginia

Any person who knowingly and with intent to defraud any insurance company or another person, iles a statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact, material thereto, commits a fraudulent insurance act, which is a crime, subject to criminal prosecution and civil penalties. In DC, LA, ME, TN and VA insurance beneits may also be denied.

Applicable in California

For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to ines and coninement in state prison.

Applicable in Colorado

It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, ines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulator y Agencies.

Applicable in Delaware, Florida and Idaho

Any person who knowingly and with the intent to injure, Defraud, or Deceive any Insurance Company Files a Statement of Claim Containing any False, Incomplete or Misleading is Guilty of a Felony. *

*In Florida – Third Degree Felony

Applicable in Hawaii

For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or beneit is a crime punishable by ines or imprisonment, or both.

Applicable in Indiana

A person who knowingly and with intent to defraud an insurer iles a statement of claim containing any false, incomplete, or misleading information commits a felony.

Applicable in Minnesota

A person who iles a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

Applicable in Nevada

Pursuant to NRS 686A.291, any person who knowingly and willfully iles a statement of claim that contains any false, incomplete or misleading information concerning a material fact is guilty of a felony.

Applicable in New Hampshire

Any person who, with the purpose to injure, defraud or deceive any insurance company, iles a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.

Applicable in New York

Any person who knowingly and with intent to defraud any insurance company or other person iles an application for commercial insurance or a statement of claim for any commercial or personal insurance beneits containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, and any person who in connection with such application or claim knowingly makes or knowingly assists, abets, solicits or conspires with another to make a false repor t of the theft, destruction, damage or conversion of any motor vehicle to a law enforcement agency, the Department of Motor Vehicles or an insurance company, commits fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed ive thousand dollars and the value of the subject motor vehicle or stated claim for each violation.

Applicable in Ohio

Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or iles a claim containing a false or deceptive statement is guilty of insurance fraud.

Applicable in Oklahoma

WARNING: Any person who knowingly and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

1127 ed 01 2013

How to Edit 24Petwatch Claim Form Online for Free

Our PDF editor allows you to fill out forms. You won't have to undertake much to update 24 petwatchi insurance claims documents. Simply keep up with all of these actions.

Step 1: To start with, select the orange "Get form now" button.

Step 2: Now, you're on the file editing page. You can add text, edit current details, highlight specific words or phrases, put crosses or checks, add images, sign the template, erase needless fields, etc.

Enter the information requested by the application to fill in the form.

You have to write down the appropriate information in the Indicate here if this is a new, Phone, Fax, Phone, Email, B TREATMENT INFORMATION, SECTIONS B D MUST BE COMPLETED BY, Treatment Information, Diagnosis and Treatment Details, Date Signs and Symptoms First, Total Treatment Cost, Has the pet been treated for this, Is there likely to be ongoing, Medical Claim, and Medical Claim area.

part 2 to entering details in pets best claim form

In the field dealing with C IN THE EVENT OF DEATH, Date of death DDMMYY, Cause of death, If euthanasia please indicate why, Were there any charges made for, yes, If so how much, D VETERINARY DECLARATION, CLINIC STAMP, I certify that the details above, Signature of veterinarian, Print Name, Date DDMMYY, E POLICY HOLDER DECLARATION, and I declare that my veterinarian, it's important to put in writing some required data.

step 3 to entering details in pets best claim form

In the field My total claim submitted is, Signed policy holder, Date DDMMYY, If you are claiming for the death, Applicable in Arizona For your, Applicable in Arkansas District Of, Any person who knowingly and with, Applicable in Indiana A person who, Applicable in Minnesota A person, Applicable in Nevada Pursuant to, Applicable in California For your, Applicable in Colorado It is, Applicable in New Hampshire Any, and Applicable in New York Any person, specify the rights and obligations of the sides.

Step 3: After you have selected the Done button, your form should be ready for upload to each gadget or email address you indicate.

Step 4: Come up with a minimum of a few copies of the document to remain away from any kind of possible concerns.

24Petwatch Claim Form – Fill Out and Use This PDF

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