24 Pet Watch Insurance Claim Form Details

The 24Petwatch Claim Form is an important document when it comes to filing a claim for your pet. This form can be found on the company's website and will provide you with all the necessary information that you need in order to file a claim. Be sure that you fill out all of the fields correctly, as well as make sure to include any supporting documentation such as vet records or photos of your damaged property. 24Petwatch provides liability coverage for dog bites, cat scratches and other damages caused by pets in their care.

You'll discover information regarding the type of form you wish to fill out in the table. It can show you just how long it should take to complete 24petwatch claim form, exactly what parts you need to fill in and a few other specific facts.

QuestionAnswer
Form Name24Petwatch Claim Form
Form Length2 pages
Fillable?Yes
Fillable fields64
Avg. time to fill out13 min 22 sec
Other names24petwatch insurance claim form, 24petwatch claim form, 24 hour pet watch, claim form pet

Form Preview Example

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:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

No

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical Claim 1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If Yes, when?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(DD/MM/YY)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

No

 

 

 

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: _____

 

Kg

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4. Were there any charges made for cremation or burial?

 

yes

 

 

no

If so, how much? $

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

D. VETERINARY DECLARATION

 

 

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

The 24 fillable completing process is very simple. Our PDF tool enables you to use any PDF document.

Step 1: Find the button "Get Form Here" on the website and select it.

Step 2: So, you can begin editing the 24 fillable. Our multifunctional toolbar is at your disposal - add, eliminate, adjust, highlight, and carry out various other commands with the content material in the document.

The following sections will make up the PDF document:

24petwatch insurance claim form blanks to fill out

Provide the demanded information in Date Signs and Symptoms First, Has the pet been treated for this, Is there likely to be ongoing, Medical Claim 1, Medical Claim 2, Yes, If Yes, Yes, (DD/MM/YY), Yes, If Yes, (DD/MM/YY), Yes, Has this pet had an annual, Yes, How long has this pet been a, Less than 12 months, More than 12 months, If this pet was referred to you, Pet’s Weight: _____, Lbs, Body Condition Score (BCS): _____, 1-5 Scale (1 = emaciated, 1-9 Scale (1 = emaciated, and 3 1 0 2 1 0 d e 7 2 1 1 part.

stage 2 to finishing 24petwatch insurance claim form

The application will demand you to put down particular key particulars to instantly fill out the field yes, If so, CLINIC STAMP, I certify that the details above, Signature of veterinarian:, Date (DD/MM/YY), and I declare that my veterinarian.

Filling in 24petwatch insurance claim form stage 3

The I understand that any, My total claim submitted is $, Signed (policy holder), Date (DD/MM/YY), If you are claiming for the death, Applicable in Arizona For your, Applicable in Arkansas, 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 section should be used to put down the rights or responsibilities of each party.

24petwatch insurance claim form I understand that any, My total claim submitted is $, Signed (policy holder), Date (DD/MM/YY), If you are claiming for the death, Applicable in Arizona For your, Applicable in Arkansas, 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 blanks to insert

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