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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.

QuestionAnswer
Form NameOspca Ontario Claim Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesform ospca form, claim ospca form, spca insurance claim, claim form ospca insurance

Form Preview Example

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:

 

 

 

Species: Dog

Cat

Breed:

 

Age:

 

 

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

1

2

3

Date

of

ns and

Total amount

Has this medical condition been

 

 

symptoms

(as noted by you, the

being claimed:

treated previously?

 

 

 

client or the pet’s medical record)

 

 

 

 

 

 

 

 

 

 

 

 

 

$

Yes

No

When:

 

 

 

 

 

 

 

 

 

 

 

 

MM

DD

YY

 

 

 

 

MM

DD

YY

 

 

 

 

 

$

Yes

No

When:

 

 

 

 

 

 

 

 

 

 

 

 

MM

DD

YY

 

 

 

 

MM

DD

YY

 

 

 

 

 

$

Yes

No

When:

 

 

 

 

 

 

 

 

 

 

 

 

MM

DD

YY

 

 

 

 

MM

DD

YY

Veterinarian Notes Please also attach veterinary history, radiology, pathology reports, and consultation notes where applicable

Pet’s Weight:

 

KG LB

Body Condition Score (BSC):

 

 

 

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

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

When was this pet registered with your practice?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MM DD

YY

 

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

 

 

 

 

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

Mail

Email

710 Dorval Drive, Suite 400

claims@ospcainsurance.ca

Oakville, Ontario L6K 3V7

 

Fax

 

1.866.368.7387

 

Questions:

 

Call OSPCA Claims at

 

1.866.600.2445