Are you considering pet insurance for your furry friend? If so, you'll want to take a look at the different types of policies and coverage available. In this blog post, we'll walk you through the process of filling out a pet insurance form so you can get an idea of what's involved. Plus, we'll share some tips on how to choose the right policy for your pet.
You can find information about the type of form you need to prepare in the table. It can tell you how much time you will need to complete pet insurance form, exactly what fields you will need to fill in, and so on.
Question | Answer |
---|---|
Form Name | Pet Insurance Form |
Form Length | 2 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 30 sec |
Other names | false, petshealth claim form, aspca pet insurance claim form, purpos |
Pet Healthcare Plan
CLAIM FORM
Ph: 1.866.725.2747 Fax: 1.919.859.8193
For office use only
______________________
______________________
______________________
______________________
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SECTION
This claim form must be filled out completely, and you must attach your itemized invoice. Incomplete forms will be returned.
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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__________________________________________________________________ |
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Policyholder Signature (REQUIRED) |
Date |
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SECTION
THIS SECTION TO BE COMPLETED BY THE VETERINARIAN (REQUIRED)
Date of Treatment |
Treatment |
Diagnosis |
________________ |
___________________________________________________ |
______________________________________ |
________________ |
___________________________________________________ |
______________________________________ |
________________ |
___________________________________________________ |
______________________________________ |
________________ |
___________________________________________________ |
______________________________________ |
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.
______________________________________ |
________________________________________ |
_____________________ |
Signature |
Print Name |
Date |
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Get it, File it, Send it!!
HOW TO GET A CLAIM FORM
∙Download a claim form from www.akcphp.com
∙Call Customer Service at 1.866.725.2747
∙
HOW TO FILE YOUR CLAIM
Filing a claim under the Pet Healthcare Plan is simple and straightforward.
∙Complete Section 1 of the claim form, and have your Veterinarian complete Section 2 (remember, incomplete forms will be returned without processing).
∙Include your itemized invoice for all services.
∙Submit your claim for reimbursement.
∙Once your claim is completed you will receive a claims explanation of benefits explaining how your claim was processed.
**Remember to file your claim form and itemized receipts within the required timely filing limit.
3 EASY WAYS TO SEND FORMS
FAX |
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ELECTRONIC |
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Raleigh, NC
Fraud Warning:
Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance or 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 and may subject such person to criminal and civil penalties.