Shelter Care Claim Form PDF Details

When pet owners face the unfortunate event of their pet needing medical attention, the Shelter Care Claim form, underwritten by Praetorian Insurance Company in New York, provides a structured process to claim insurance benefits. This form necessitates the complete and accurate provision of all sections, accompanied by a paid itemized invoice and the pet’s comprehensive medical records from both current and prior veterinary clinics. The purpose is to streamline the claims process, mandating a meticulous compilation of the pet's and owner's information, specific details of the medical condition claimed for, and the corresponding diagnosis and treatment expenses. Veterinary professionals play a critical role, as their input in sections concerning diagnosis and procedural declarations is essential. Detailed invoices, explicit evidence of diagnoses, and the pet’s condition, alongside a thorough medical history, bolster the credibility of the claim. Policyholders are urged to ensure that all information provided is accurate and complete to avoid delays or denial due to omissions or inaccuracies, keeping in mind that any attempt to misrepresent or defraud can lead to severe legal consequences based on the jurisdiction. This form not only represents a financial recourse for pet owners but reinforces ethical and legal accountability in the administration of pet insurance claims. The process underscores the importance of transparent communication between pet owners, veterinary professionals, and the insurance company, aiming to facilitate the swift and fair reimbursement for medical expenses incurred.

QuestionAnswer
Form NameShelter Care Claim Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesfalse, repor, insurer, hawaii

Form Preview Example

Claim Form

Underwritten by Praetorian Insurance Company, NY

INSTRUCTIONS: Please complete ALL sections on this form and submit with your paid itemized invoice and pet’s medical history. Only one claim form per pet. A complete veterinary medical history (records) from both current and previous veterinary clinics is required to process your pet’s ollow the Claims Checklist to avoid delays in processing.

Claims Checklist

Complete Section 1 About You and Your Pet

Include your Policy Number

Include your Contact Information

Review your Policy Documents and Terms and Conditions to see if coverage is available for the current medical condition you are claiming for

Have the treating veterinarian complete Sections 2 and 3

Sign your claim form in the Declarations Section (Section 3) Attach detailed paid invoices for condition(s) you are claiming for

*Missing information, signatures, or required supporting documents will result in delays in processing your claim

Medical Records Include:

Detailed examination or SOAP notes

Lab/pathology/radiology reports

Medical reports from referral or emergency hospitals

Transaction histories and invoices are not accepted

Invoices Must Be:

Detailed and Itemized indicating the cost and treatment

Paid, unless reimbursement is to be made and agreed to by the veterinarian Account Summaries are not accepted

SECTION 1A: Your Pet’s Information

Policy Number:

Pet Name:

 

 

 

Species: Dog

Cat

Breed:

 

Age:

 

 

SECTION 1B: Your Information

Your Name:

Mailing Address:

Email Address:

Home Number:

Cell Number:

Check here if there has been a change to your address or phone number

SECTION 2: About Your Claim To be completed by the treating licensed Veterinarian

Diagnosis

List each separate diagnosis clearly

1

2

3

Date

of

ns and

Total amount

Has this medical condition been

 

 

symptoms

(as noted by you, the

being claimed:

treated previously?

 

 

 

client or the pet’s medical record)

 

 

 

 

 

 

 

 

 

 

 

 

 

$

Yes

No

When:

 

 

 

 

 

 

 

 

 

 

 

 

MM

DD

YY

 

 

 

 

MM

DD

YY

 

 

 

 

 

$

Yes

No

When:

 

 

 

 

 

 

 

 

 

 

 

 

MM

DD

YY

 

 

 

 

MM

DD

YY

 

 

 

 

 

$

Yes

No

When:

 

 

 

 

 

 

 

 

 

 

 

 

MM

DD

YY

 

 

 

 

MM

DD

YY

Veterinarian Notes Please also attach veterinary history, radiology, pathology reports, and consultation notes where applicable

Pet’s Weight:

 

KG LB

Body Condition Score (BSC):

 

 

 

1-5 Scale (1=Emaciated, 5=Obese)

1-9 Scale (1=Emaciated, 9=Obese)

When was this pet registered with your practice?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MM DD YY

If this pet was referred to you, please give the name of the referring practice:

SUBMIT A CLAIM

Email medicals@pethealthinc.com

Fax: 1.866.369.7387

Continue to Page 2

 

 

 

 

SECTION 3: Declarations

Policyholder Declaration

Veterinarian Declaration

I declare that my veterinarian recommended the treatment for which I am claiming. The veterinary clinic has completed Section 2 and the particulars given are correct to the best of my knowledge and belief. I agree that my veterinarian may provide information that the company may require to verify a claim. I understand that any misrepresentation or omission of any material fact can result in denial of the claim and I conm my understanding of the applicable fraud warning below.

I declare that diagnosis and particulars given in Section 2 in regards to the treatment of this pet are correct to the best of my knowledge and belief. I agree to provide information that the company may require to verify a claim. I understand

that any misrepresentation or omission of any material fact can result in denial of the claim.

Signature of Policyholder

Signature of Veterinarian

Date:

Print Veterinarian Name:

MM DD YY

Date:

MM DD YY

Please submit completed claims by:

CLINIC STAMP

Mail

Email

P.O. Box 2150

medicals@pethealthinc.com

Bu, NY 14240-2150

 

Fax

 

1.866.369.7387

 

Questions:

 

Call our Customer Care Unit at

 

1.877.707.7297

 

 

 

Applicable in Alaska

A person who knowingly and with intent to injure, defraud, or deceive an insurance company osecuted under state law.

Applicable in District of Columbia

WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or an insurer may deny insurance beneelated to a claim was provided by the applicant.

Applicable in Alabama, Arkansas, Louisiana, Maryland, Rhode Island, Texas, Utah and West Virginia

Any person who knowingly presents a false or fraudulent claim for payment of a loss or beneesents false information in an application for insurance is guilty of a crime and may be subject to con

Applicable in Arizona

For your protection, Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties.

Applicable in Kentucky, Michigan, New Jersey, New Mexico and Pennsylvania.

Any person who knowingly and with intent to defraud any insurance company or another person, ading, information

concerning any fact, material thereto, commits a fraudulent insurance act, which is a crime, subject to criminal prosecution and civil penalties. In DC, LA, ME, TN and VA insurance bene denied.

Applicable in California

For your protection, California law requires the following to appear on this form: Any person who knowingly presents a false or fraudulent claim for payment of a loss is guilty of a crime and may be subject to con

Applicable in Colorado

It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policy holder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulator y Agencies.

Applicable in Delaware, Florida and Idaho

Any person who knowingly and with the intent to injure, Defraud, or Deceive any Insurance Company Files a Statement of Claim Containing any False, Incomplete or Misleading is Guilty of a Felony. * *In Florida – Third Degree Felony

Applicable in Hawaii

For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or bene

Applicable in Indiana

A person who knowingly and with intent to defraud an insurer .

Applicable in Minnesota

A person who er is guilty of a crime.

Applicable in Nevada

Pursuant to NRS 686A.291, any person who knowingly and willfully ning a material fact is guilty of a felony.

Applicable in New Hampshire

Any person who, with the purpose to injure, defraud or deceive any insurance company, osecution and punishment for insurance fraud, as provided in RSA 638:20.

Applicable in New York

Any person who knowingly and with intent to defraud any insurance company or other person ls for the purpose of

misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed thousand dollars and the stated value of the claim for each such violation.

Applicable in Ohio

Any person who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or insurance fraud.

Applicable in Oklahoma

WARNING: Any person who knowingly and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

In the state of WA and all other states not mentioned above and Puerto Rico; it is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment,

How to Edit Shelter Care Claim Form Online for Free

This PDF editor makes it easy to fill in forms. There's no need to perform much to manage shelter care pet insurance claim form forms. Just follow the next actions.

Step 1: You can press the orange "Get Form Now" button at the top of the page.

Step 2: Now you're on the form editing page. You may enhance and add text to the form, highlight specified content, cross or check certain words, insert images, put a signature on it, erase unneeded areas, or eliminate them altogether.

These particular areas are what you will need to prepare to get your ready PDF document.

step 1 to filling out ShelterCare

The software will require you to submit the Diagnosis List each separate, Date of first clinical signs and, Total amount being claimed, Has this medical condition been, MM DD YY, MM DD YY, MM DD YY, Yes No When, Yes No When, Yes No When, MM DD YY, MM DD YY, MM DD YY, Veterinarian Notes Please also, and Pets Weight part.

Finishing ShelterCare part 2

You could be required some relevant particulars to be able to prepare the I declare that my veterinarian, Signature of Policyholder, Date, MM DD YY, Signature of Veterinarian, Print Veterinarian Name, Date, MM DD YY, Please submit completed claims by, CLINIC STAMP, Email medicalspethealthinccom, Mail PO Box Buffalo NY, Fax, Questions Call our Customer Care, and Applicable in Alaska A person who section.

Filling out ShelterCare stage 3

Step 3: Hit the button "Done". Your PDF file can be exported. It's possible to upload it to your pc or send it by email.

Step 4: Make copies of the document. This may protect you from future challenges. We cannot watch or publish your data, thus feel comfortable knowing it will be protected.

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