If you have ever been involved with a serious car accident, you know that filing an insurance claim can be a daunting task. The Ospca Ontario Claim Form is no different. This form is used to file a claim for property damage or personal injury caused by an animal belonging to the Ontario Society for the Prevention of Cruelty to Animals (ospca). In this blog post, we will provide a step-by-step guide on how to fill out the Ospca Ontario Claim Form. We will also discuss some of the important information that needs to be included in the form.
The listing contains information about the ospca ontario claim form. You can learn its size, the actual time required to complete the form, the blanks you'll have to fill in, etc.
| Question | Answer |
|---|---|
| Form Name | Ospca Ontario Claim Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | form ospca form, claim ospca form, spca insurance claim, claim form ospca insurance |
Claim Form
Underwritten by Northbridge General Insurance Corporation
INSTRUCTIONS: Please complete ALL sections on this form and submit with your paid itemized invoice and pet’s medical history. Only one claim form per pet. A complete veterinary medical history (records) from both current and previous veterinary clinics is required to process your pet’s ollow the Claims Checklist to avoid delays in processing.
Claims Checklist
Complete Section 1 About You and Your Pet
Include your Policy Number
Include your Contact Information
Review your Policy Documents and Terms and Conditions to see if coverage is available for the current medical condition you are claiming for
Have the treating veterinarian complete Sections 2 and 3
Sign your claim form in the Declarations Section (Section 3) Attach detailed paid invoices for condition(s) you are claiming for
*Missing information, signatures, or required supporting documents will result in delays in processing your claim
Medical Records Include:
Detailed examination or SOAP notes
Lab/pathology/radiology reports
Medical reports from referral or emergency hospitals
Transaction histories and invoices are not accepted
Invoices Must Be:
Detailed and Itemized indicating the cost and treatment
Paid, unless reimbursement is to be made and agreed to by the veterinarian Account Summaries are not accepted
SECTION 1A: Your Pet’s Information
Policy Number: |
Pet Name: |
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Species: Dog |
Cat |
Breed: |
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Age: |
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SECTION 1B: Your Information
Your Name:
Mailing Address:
Email Address:
Home Number: |
Cell Number: |
Check here if there has been a change to your address or phone number
SECTION 2: About Your Claim To be completed by the treating licensed Veterinarian
Diagnosis
List each separate diagnosis clearly
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Total amount |
Has this medical condition been |
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symptoms |
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being claimed: |
treated previously? |
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client or the pet’s medical record) |
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Veterinarian Notes Please also attach veterinary history, radiology, pathology reports, and consultation notes where applicable
Pet’s Weight: |
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KG LB |
Body Condition Score (BSC): |
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When was this pet registered with your practice? |
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If this pet was referred to you, please give the name of the referring practice:
SUBMIT A CLAIM |
Email claims@ospcainsurance.ca |
Fax: 1.866.368.7387 |
Continue to Page 2 |
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SECTION 3: Declarations
Policyholder Declaration |
Veterinarian Declaration |
I declare that my veterinarian recommended the treatment for which I am claiming. The veterinary clinic has completed Section 2 and the particulars given are correct to the best of my knowledge and belief. I agree that my veterinarian may provide information that the company may require to verify a claim. I understand that any misrepresentation or omission of any material fact can result in denial of the claim.
I declare that diagnosis and particulars given in Section 2 in regards to the treatment of this pet are correct to the best of my knowledge and belief. I agree to provide information that the company may require to verify a
claim. I understand that any misrepresentation or omission of any material fact can result in denial of the claim.
Signature of Policyholder |
Signature of Veterinarian |
Date:
Print Veterinarian Name:
MM DD YY
Date:
MM DD YY
Please submit completed claims by:
CLINIC STAMP
710 Dorval Drive, Suite 400 |
claims@ospcainsurance.ca |
Oakville, Ontario L6K 3V7 |
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Fax |
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1.866.368.7387 |
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Questions: |
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Call OSPCA Claims at |
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1.866.600.2445 |
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