Pet Insurance Form – Fill Out and Use This PDF

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:

___________________________________________________________________________________________________

___________________________________________________________________________________________________

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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

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)

 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.