Pet Plan Claim Form – Fill Out and Use This PDF

The Pet Plan Claim Form is a way to receive pet insurance claims.

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Pet Plan Claim Form first page preview

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.

Question	Answer
Form Name	Pet Plan Claim Form
Form Length	2 pages
Fillable?	Yes
Fillable fields	120
Avg. time to fill out	24 min 34 sec
Other names	petplan claim form pdf download, petplan claim form canada pdf, petplan claim form, petplan insurance claim form

12

Form Preview Example

For Petplan use only

We’re happy to help!

If you have any questions call us on

0800 255 426

the pet insurance people

Claim Form for Veterinary Fees

Are you completing this form for a: New illness or injury Continuation illness or injury

Complete ALL sections clearly and in full. Complete sections shaded yellow only.

Please complete the claim form fully, using a black pen and block capitals. Missing information will delay your claim.

Please use a separate claim form for each pet, each illness or injury and each treating veterinary practice.

1. Policyholder to complete	POLICY NUMBER
2. Policyholder to complete	ABOUT YOU
Policyholder’s
surname

First name

Contact no.

Email address

3. Policyholder to complete

ABOUT YOUR PET

Pet’s name

Pedigree name

(If applicable)

If this is the first claim you are submitting for your pet you must include a full clinical history from all of the vets that your pet has been registered with, plus any information you may have from the person/party you obtained your pet from. Your claim will be delayed if this is not included.

4. Policyholder to complete

DETAILS OF YOUR PET’S ILLNESS

What condition(s) are you claiming for?

Please tell us the date you first noticed any signs that your pet was unwell or injured before booking an appointment with your vet. Your claim will be delayed if we do not have this information.

	Date and time Condition first noticed				AM	/ PM

	Date and time pet seen by vet				AM	/ PM

	Did the illness or injury result in the death of your pet?		Yes		No
	Did the illness or injury result in the death of your pet?		Yes		No
	Date of death
	Date of death

5. Policyholder to complete		PAYEE DETAILS

Payments will be automatically made payable to the policyholder(s) named on your Certificate of Insurance, unless we are instructed otherwise.

Is any insured registered for GST?

Yes

No

PLEASE COMPLETE ONE OF THE FOLLOWING

Please note we will not pay your vet unless it has been previously agreed with them to do so. Please check with your vet.

A. Pay Vet - please tick

I/We have arranged with my/our vet and would like this claim paid directly to them, less my excess and any other non-claimable items.

Name of the vet practice

Customer ID

Account Name

Account Number

Vet practice sign here	Date:

B. Pay Policyholder(s) - please tick

I/We wish the claim to be paid to the policyholder(s) name on the Certificate of Insurance.

Name

Account Name

Account Number

IMPORTANT NOTES

Please send completed claim forms including all receipts to

Petplan Australasia Pty Ltd, PO Box 112250, Penrose Auckland 1642

Petplan Australasia 2097390 administers the policy on behalf of Allianz Australia Insurance Limited ABN 15 000 122 850 (Incorporated in Australia) trading as Allianz New Zealand which underwrites the policy.

Policyholder’s address

Postcode

Please tick here if this is different to the address on your Certificate of Insurance. Your policy records will be updated with these details.

Dog		Cat			Pet’s date of birth


Breed						Male			Female


Is this pet insured with any other company?						Yes			No
If Yes, please state which company
If Yes, please state which company

Have you, or are you intending to lodge a claim for this						Yes			No
Have you, or are you intending to lodge a claim for this
illness/injury with them?
illness/injury with them?

Please tell us the names and addresses of all the vet practices where the pet has been treated before or the vet that referred you. Please use a separate sheet of paper for more than one.

Practice Name

Address

Postcode

Phone

Date: from	to

If your pet was injured, please provide details of how the injury occurred, on a separate sheet of paper. If anyone else is responsible for the injury, please provide their name and address.

Not covered by your policy - Routine and preventative healthcare eg. shampoo, nail clipping, teeth cleaning, worming, desexing and vaccination, any illness within your waiting period and pre-existing conditions.

INCOMPLETE CLAIM FORMS WILL BE RETURNED TO THE POLICYHOLDER(S)

In order for your claim form to be processed in a timely manner please make sure that you have completed the claim form in full, have your vet complete their section, and it is signed by both You and Your Vet, and includes itemised invoices.

Please complete the checklist, read the Privacy statement and sign the form below.

Are all the sections of the claim form completed?

Has the Vet completed all their sections of the claim?

Have you included all itemised invoices with your claim?

Have you and the vet signed the claim form?

Privacy: The Privacy Act 1993 requires us to tell you that as an insurer we collect your personal and sensitive information in order to calculate your loss and entitlement, determine our liability, compile data and handle claims. When handling claims, we may disclose your personal and other information to third parties such as other insurers, loss adjusters, external claims data collectors, investigators and agents, to the Insurance Reference Service (IRS), etc., or other parties as required by law.

You have the right to seek access to your personal information and to collect it at any time. Please contact us on 0800 255 426 8:30am-5pm Mon-Fri and advise us of the changes.

IDR Statement: Disputes are not an everyday occurrence at Petplan. However we do provide an internal dispute resolution process should any dispute arise. Please feel free to ask for details. If you are not satisfied with the outcome of this process, we will advise you how to contact the insurance industry’s external independent complaints scheme (subject to eligibility).

I/We certify the information given on this form is truthful, accurate and complete. No information likely to affect this claim has been withheld. I/We understand that this claim may be refused

if information is untrue, inaccurate or concealed. I/We acknowledge that I/we have read and understood the Privacy Act 1993 and consent to the collection, storage, use and disclosure of personal and sensitive information to all persons affected by this claim. I/We acknowledge that if I/we do not agree to the collection of this personal and sensitive information then Petplan will be unable to process my/our claim.

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

Please sign here	Date:

New illness or injury - Complete ALL sections clearly and in full.

Continuation illness or injury - Complete sections shaded yellow only.

IF THIS IS THE FIRST CLAIM FOR THIS PET, PLEASE SUBMIT A FULL CLINICAL HISTORY

ASK YOUR VET TO COMPLETE THESE THREE SECTIONS

6. Vet practice to complete

GENERAL INFORMATION

When was this pet first registered at your practice?

If this pet has been referred please give the name, address and telephone number of the practice which referred it.

Name

Address

Telephone number

In connection with the treatment claimed, did you make a house visit	Yes		No

or provide out of hours treatment?
or provide out of hours treatment?
If Yes, why?

Is any part of this claim for a condition the pet can be					Yes			No
vaccinated against?
vaccinated against?
If Yes, were the pet’s vaccinations up to date at the time of treatment?
Yes		Please give date	No				Don’t Know
Yes		of last vaccination
		of last vaccination

Is any part of this claim for dental treatment?					Yes			No
Is any part of this claim for dental treatment?					Yes			No

If Yes, please enclose a full clinical history over the last 2 years. Not providing this will delay the client’s claim.

Is any part of this claim for treatment of a urinary problem?	Yes		No
If Yes, is the cost of diet food included in this claim?	Yes		No

If Yes, please provide the name of the diet food being used and total cost being claimed.

Name			Amount	$

In case of a urinary problem, were crystals present?			Yes		No
In case of a urinary problem, were crystals present?			Yes		No
If Yes, are the crystals:	Oxalate		Struvite		Other

If other, please specify

Please give dates and results of last 2 urine tests

Date:Result

Date:Result

7. Vet practice to complete

ABOUT THE ILLNESS OR INJURY

Condition

Name of the illness or injury

(if no diagnosis has been made, please give clinical signs)

Did death or euthanasia result from this illness or injury?		Yes		No
Date of death


If the pet was put to sleep, did you recommend this?		Yes		No
Is this claim a continuation of a previous claim?		Yes		No


Treatment date: from	to
Treatment date: from

When did this illness or injury begin or show clinical signs?

(as started by the client and noted in your records)

To your knowledge, has this pet been seen before for:
This illness or injury	Yes		No

Any similar or related illness or injury	Yes		No


Any similar or related clinical signs	Yes		No

If Yes, please provide the history with dates

Date:

Date:

Total amount being claimed (inc. GST)

$

PLEASE ENCLOSE FULL ITEMISED INVOICES AND RECEIPTS TO SUPPORT THIS CLAIM

8. Vet practice to complete	DECLARATION BY VETERINARY PRACTICE
This practice is authorised to have the claim(s) paid direct		Yes		No
		Yes		No

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

Position in practice

Phone

Fax

Email

Vet practice stamp here

Signature	Date:
(Vet practice manager)

PLEASE USE A SEPARATE CLAIM FORM FOR EACH PET, EACH ILLNESS OR INJURY AND EACH TREATING VETERINARY PRACTICE PLEASE SEND COMPLETED FORMS INCLUDING ALL RECEIPTS TO:

PETPLAN AUSTRALASIA PTY LTD, PO BOX 112250, PENROSE AUCKLAND 1642

Once we have received and lodged your claim, an acknowledgement will be sent to the contact details that we have on record. If you do not receive the acknowledgment, feel free to call our customer care centre at 0800 255 426 to update your details on Petplan’s records and to confirm that your claim has been received and lodged.

If this is your first claim, we will request a complete medical history for your pet. To fast track the history requesting process you may attach the complete medical history to your claim and provide us with the date you took on ownership of your pet and all vets attended whilst in your care.

If you need an update on the status of your claim during the time that it is being processed, you can email us on

info

@

petplan.net.nz

All claims are processed in order of receiving them and we will deal with your claim as quickly as possible.

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step 1 to completing petplan canada claim form

Provide the demanded data in the box What, conditions, are, you, claiming, for Practice, Name Address, Phone, Postcode, AM, PM Date, from AM, PM Date, and, time, Condition, first, noticed Date, and, time, pet, seen, by, vet Yes, Date, of, death Policyholder, to, complete PAYEE, DETAILS and Yes.

petplan canada claim form Whatconditionsareyouclaimingfor, PracticeName, Address, Phone, Postcode, AMPM, Datefrom, AMPM, DateandtimeConditionfirstnoticed, Dateandtimepetseenbyvet, Yes, Dateofdeath, Policyholdertocomplete, PAYEEDETAILS, and Yes blanks to fill out

Write down the main details in Customer, ID Account, Name Account, Number Vet, practice, sign, here Date, B, Pay, Policyholders, please, tick Account, Name Account, Number Have, you, and, the, vet, signed, the, claim, form Please, sign, here and Date field.

stage 3 to completing petplan canada claim form

Please include the rights and responsibilities of the parties inside the Please, give, date, of, last, vaccination Yes, Dont, Know Yes, Yes, Amount, Yes, Vet, practice, to, complete GENERAL, INFORMATION Name, Address, Telephone, number Yes, Yes, and If, Yes, why part.

Entering details in petplan canada claim form step 4

End by reading the following fields and completing them as required: Any, similar, or, related, clinical, signs Yes, Date, Date, Date, of, death Treatment, date, from Yes, Yes, Yes, Total, amount, being, claimed, inc, GST Vet, practice, to, complete DECLARATION, BY, VETERINARY, PRACTICE Vet, practice, stamp, here Yes, and Name.

Filling in petplan canada claim form part 5

Step 3: Select the Done button to make sure that your finalized document can be transferred to each gadget you pick out or mailed to an email you indicate.

Step 4: Be certain to avoid forthcoming difficulties by preparing no less than two duplicates of the document.

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