Owner & Pet Information - This section to be completed by the policyholder
Last Name: _______________________________ First Name: ___________________ Policy Number: ___________________
Street: ________________________________ City & State: ______________________, _____ Zip Code: ___________
Phone Number: ________________________ Email Address: _______________________________________________
□Check here and update above if you have new contact information
Name of Pet: _______________________________________________________________________________________
Call Name: _________________________________________________________________________________________
Breed: _____________________________________________ Sex: _____________ Age: ______________
First Date of Injury, Illness or Condition: __________________________________
Please provide a brief description of illness/injury/condition:
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
POLICYHOLDER DECLARATION: I confirm that all details provided herein are true and accurate. I understand that I am financially responsible to the Veterinarian for the entire treatment. I also understand that the deliberate misrepresentation of the animal’s condition or
the omission of any material facts may result in the denial of the claim and/or the cancellation of coverage. I authorize the insuring company and its authorized representatives to review and obtain a copy of all records including the insurance claim records and medical records as to the examination, history, treatment and prognosis with respect to any condition. I understand that all charges from my
Veterinarian may not be covered or may exceed my plan benefits. |
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Policyholder Signature (REQUIRED) |
Date |
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SECTION -2- Please have your Veterinarian provide information pertaining to the invoices submitted with this claim.
THIS SECTION TO BE COMPLETED BY THE VETERINARIAN (REQUIRED)
Date of Treatment |
Treatment |
Diagnosis |
________________ |
___________________________________________________ |
______________________________________ |
________________ |
___________________________________________________ |
______________________________________ |
________________ |
___________________________________________________ |
______________________________________ |
________________ |
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______________________________________ |
Length of time pet has been registered at your practice? ___________ Has the pet been treated for a related problem? Yes/No
If yes, please provide detailed information of the treatment or any related conditions:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
Name and phone number of previous or referring Veterinarian: ____________________________________________________________
VETERINARIAN DECLARATION: I certify that to the best of my knowledge all the information contained on this form is correct. I also understand it is a criminal act to assist in the preparation or presentation of a false or fraudulent claim under an insurance policy.
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Signature |
Print Name |
Date |
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