Pet Plan Claim Form PDF Details

A pet plan claim form can be a daunting document to fill out, but it is important to make sure all the necessary information is included. The form can be used to request reimbursement for veterinary expenses related to an illness or injury your pet has suffered. Knowing what to include and how to submit the form will ensure that you receive the money you need to cover your pet's care.

You can find more information concerning the pet plan claim form by checking out the table we prepared.

QuestionAnswer
Form NamePet Plan Claim Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namespetplan claim form pdf, petplan claim form, petplan claim form printable, petplan claim form pdf download

Form Preview Example

CLAIM FORM FOR VETERINARY FEES

IMPORTANT NOTES

Pet Plan Ltd administers the policy on behalf of Allianz Insurance plc which underwrites the policy.

If the claim is being faxed, please retain all the original copies of the claim form and receipts.

Please use a separate claim form for each pet.

Please send completed claim forms including copies of all receipts to:

Pet Plan Ltd, FREEPOST SEA0883, Brentford, TW8 9YY.

CLAIM FORMS RECEIVED WHICH ARE INCOMPLETE WILL BE RETURNED TO THE POLICYHOLDER.

Certificate Number

1.About you (To be completed by the policyholder)

Policyholder’s name

Policyholder’s address and postcode

Daytime phone number

Evening phone number

For Petplan use only

Contacting Petplan

If you have any questions, call:

0845 074 4406

Please tick here if this is different to the address on your Certificate of Insurance.

2.About your pet (To be completed by the policyholder)

Your pet’s name

Pedigree name

Dog

Cat

Rabbit

Male

Female

How we work out your payment

What we will pay

We will pay the cost of any treatment received during the period of cover up to the maximum benefit.

Did the illness or injury result in the death of your pet?

Breed

Date of Birth

Name of each illness or injury you are claiming for, and the date when you first noticed

any signs

Veterinary surgeries where your pet has been registered before

If there is more than one, please use a separate piece of paper

Yes

No

/ /

1

2

Name

Address

date / /

date / /

We will deduct

the part of the claim you have to pay for each illness or injury (the excess).

We will also deduct

the cost of treatment which your policy does not cover. Please see the ‘What we will not pay’ section of your Pet insurance policy terms and conditions.

We will also take off

the cost of treatment for:

any illness or injury which first happened or showed signs before your pet’s cover started; and

any illness or injury shown as excluded on your certificate of insurance.

If we decide that we cannot pay some or all of your claim, you will have to pay your vet for any treatment we have not paid.

Telephone No.

Date: From

/

/

-

To

/

/

3. Payee details

Cheques will automatically be made payable to the Policyholder(s). Please tick ‘Other’ if you

 

Vet

 

Other

require only one Policyholder to be paid or ‘Vet’ if you require the vet to be paid directly.

 

 

 

 

 

 

 

Please enter the Payee name and

 

 

 

 

 

 

 

 

 

 

 

 

 

 

sign below to authorise payment.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature

 

 

 

 

 

 

 

 

 

 

 

 

Pet Plan Ltd is a subsidiary of Allianz

Insurance plc who is authorised and regulated by the Financial Services Authority (FSA). Allianz Insurance plc’s

FSA Register number is 121849. This can be checked by visiting the FSA website at www.fsa.gov.uk/register or by contacting the FSA on 0845 606 1234.

Allianz Insurance

plc underwrites the policy and Pet Plan Ltd administers the policy.

06/05

CLAIM FORMS RECEIVED WHICH ARE INCOMPLETE WILL BE RETURNED TO THE POLICYHOLDER.

5702/5

4. About the illness or injury (To be completed by your vet)

 

Illness or injury 1

 

 

 

 

 

 

 

Illness or injury 2

 

 

 

 

 

 

 

Name of the illness or injury

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

if no diagnosis has been made please

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

give clinical signs

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is this claim a continuation?

 

 

 

Yes

 

 

 

No

 

 

 

 

 

 

Yes

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

When did this illness or injury

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

date

/

/

 

 

 

 

 

 

 

 

 

date

/

/

 

 

 

 

 

 

 

 

begin (as noted on your records)?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Treatment dates

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

date

/

/

 

 

 

date

/

/

 

 

 

date

/

/

 

 

 

date

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Did death or euthanasia result

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

 

 

No

 

 

 

 

 

 

Yes

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

from this illness or injury?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If the pet was put down, did you

 

 

 

Yes

 

 

 

No

 

 

 

 

 

 

Yes

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

recommend this?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

When was this pet first registered

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

date

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

at your practice?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If this pet has been referred

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

please give the name and

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

telephone number of the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

practice which referred it

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone No.

To your knowledge has this pet been seen before for:

Is any part of this claim for dental treatment?

Is any part of this claim for treatment of a urinary problem?

If Yes: Is the cost of diet food included in this claim?

• This illness or injury

 

 

 

 

 

 

 

 

 

 

• Any similar or related illness or injury: or

 

Yes

 

No

 

 

 

 

 

 

 

 

• Any similar or related clinical signs

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If Yes, please provide the history with dates?

 

 

 

 

 

date

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

date

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

If you have answered Yes, please enclose

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a full dental history over the last 2 years

 

 

 

 

 

 

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

 

No

If Yes, please provide the name of the diet food

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

being used and total cost being claimed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name

 

 

 

 

 

Amount £

 

.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Were crystals present?

 

Yes

 

 

 

No

If Yes, are the Crystals

 

 

 

Oxylate

 

Struvite

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If other, please specify

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please give dates of last two

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

date

/

/

 

 

 

date

/

/

 

 

 

 

 

 

 

 

 

 

urine tests

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

In connection with treatment

Make a house visit?

 

Yes

 

No

or provide out of hours treatment?

 

 

Yes

 

 

 

 

claimed did you:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No

If Yes, why was this house visit/out of hours treatment necessary?

Total amount claimed (inc VAT)

Illness or injury 1

£.

Illness or injury 2

£.

Please enclose full invoices to support this claim

Please enclose full invoices to support this claim

 

 

5. Declaration by the Veterinary practice (To be completed by your vet)

 

 

 

I have checked the information on this claim form and confirm that it is all correct to the best of my knowledge and belief.

Name

Signature

date / /

Vet stamp

Petplan Practice No.

6. Declaration by the Policyholder (To be completed by the policyholder)

Are you happy for Pet Plan Ltd to provide the vet detailed on this form with information about your policy in respect to this claim?

I have checked the information

 

Signature

on this claim form and confirm

that it is all correct to the best

of my knowledge and belief.

Your signature if there are two

 

Signature

 

policyholders shown on the Certificate of

 

Insurance each one must sign

 

 

 

Yes

No

date / /

date / /

CLAIM FORMS RECEIVED WHICH ARE INCOMPLETE WILL BE RETURNED TO THE POLICYHOLDER.

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