Tesco Pet Insurance Form PDF Details

Pet insurance is an important topic for pet owners to consider. By taking out pet insurance, you can help protect your furry friend in the event that something happens and they need expensive veterinary care. In this blog post we will take a look at the Tesco Pet Insurance form, so that you can learn more about what is involved in taking out this type of insurance policy.

In the table, there is some good information regarding the tesco pet insurance form. It might be helpful to learn its length, the actual time to fill out the form, the blanks you'll need to fill in, and so on.

QuestionAnswer
Form NameTesco Pet Insurance Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namestesco pet insurance claim form, tesco claim form, tesco pet form, tesco claims form

Form Preview Example

Claim Form

Claims Helpline: 0845 078 3860 tesco.petclaims@uk.rsagroup.com

To be completed and returned to: Tesco Pet Insurance, Freepost - RSJG-ZJTB-GAGH, PO Box 15770, Birmingham, B2 2RB or for a quicker way of submitting your claim to us please email a scanned copy to tesco.petclaims@uk.rsagroup.com

A. About you (the Policyholder)

If your name or address has changed, please tick

Name, address and postcode

Daytime tel

Evening tel

Mobile tel

Email

If you provide us with your mobile number and email address, we can let you know we have received your claim form.

Policy number

PLEASE NOTE that if any section of the form is not filled in, it may delay your claim – you MUST fill in sections A to E.

Please also read the following notes before submitting any claim and have your policywording to hand for full details:

Your policy does NOT COVER in whole or as part of a claim:

Any condition that started before the policy start date

Any condition that started within the qualifying period of the policy start date

The excess specified in your policy schedule

Food

Flea treatment

Wormers

Vaccinations

If a claim for a new condition please ensure the full medical history is attached to the claim form.

B. About your pet

Your pet’s name (* multipet)

*If you have more than one pet insured with us, please ensure you enter the correct pet’s name and only one claim form per pet.

Cat

 

 

 

Dog

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Male

 

 

 

Female

 

 

 

 

 

 

Breed

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has your pet been

Yes

 

 

 

No

 

 

 

 

 

 

 

 

 

neutered/spayed?

 

 

 

 

 

 

 

 

 

 

kgs

What is the weight of your pet?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Note: If you are not sure about any of the above information, please ask your vet to complete this for you.

C. About your pet’s condition

Condition 1

Condition 2

Name of condition as advised by your vet

Please tell us when you first noticed your pet was unwell or injured, that led you to make an appointment with your vet.

Time and date

Time and date

Did you contact our vetfone service?

Was your pet under your care at the time of the illness/injury/incident?

If no, please provide the name and address of any authorised third party looking after your pet at the time of the incident

Yes

Yes

No

No

Date

If your claim is for an injury, do you believe that another person was at fault?

Yes

If so, please provide details separately

 

No

D. Your previous veterinary practices (Please tell us all vet(s) where your pet was previously registered)

Practice name

Address

Postcode

Phone number

Date: from

to

Practice name

Address

Postcode

Phone number

Date: from

to

Please tell us your name and address at that time, if it was different to the name and address in Section A

Postcode

E. Your signature (Policyholder – please complete one of the following boxes (a, b or c) to tell us who to pay)

I declare, to the best of my knowledge and belief, that all the information provided in this form is true and complete. I agree that RSA may seek any information it requires from any vet. I accept that the information provided may be released to other companies who provide a service to us or you in connection with managing and handling claims

i)Please pay my claim direct to me Printed name:

Policyholder’s signature:

ii)Please pay my claim direct to my vet Printed name:

Policyholder’s signature:

iii)Please pay my claim direct to the person named below:

Printed name: Policyholder’s signature:

Date:

Date:

Date:

Please note: if we decide we cannot pay some or all of your claim, it is your responsibility to pay your vet.

F. Your vet must fill in this section about each condition (We only accept claim forms from veterinary practices)

Please advise the date this pet was registered at your practice.

If this pet was referred to you, please advise the name and address of the registered vet

Postcode

Was this pet referred to a complementary

If Yes, please advise the condition

treatment professional?

 

 

 

 

Yes

No

 

If Yes, please also complete Sections G & H

Did any condition being claimed result in the death or euthanasia of the pet?

Yes

No

Date of death

If your claim involves dental or gum treatment, was this caused by an injury? Yes

No

If a house call was made, you must confirm in writing why it was absolutely essential

 

Condition 1

 

 

 

What are the main clinical signs?

 

 

 

 

 

 

 

 

 

 

What is the diagnosis? (This must be completed)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please tell us the treatment dates for this claim From

 

 

To

 

Have you filled in a claim for this condition

 

 

 

 

 

Yes

No

 

Don’t know

before?

 

 

 

 

 

 

From

 

 

To

 

If yes, treatment dates from the previous claim

 

 

 

 

 

 

 

 

 

 

Condition 2

From

 

To

 

Yes

 

 

 

No

 

Don’t know

 

 

 

From

 

To

 

 

 

 

 

IF THIS IS A NEW CLAIM, PLEASE COMPLETE THE FOLLOWING QUESTIONS AND FORWARD THE FULL MEDICAL HISTORY. Please tell us the date or the number of days before the first date of treatment, that the clinical signs were first noticed.

Days

 

Date

 

 

 

 

 

Has this pet had this condition or clinical signs before,

Yes

No

or any related condition or clinical signs before?

 

 

(If ‘Yes’ we will need the medical history to show the dates and full details)

Days

Date

Yes

No

G.Complementary treatment (N.B. If the claim involves complementary treatment this section of the claim form must be filled in by a vet and not the complementary treatment professional. Please ensure a copy of the referral letter and invoice(s) are attached.)

What complementary treatment did you refer this pet for?

What condition is the complementary treatment for?

If you have not attached a copy of the referral letter or the letter does not contain the following information, please tell us:

How many sessions have you recommended? Please tell us the cost of complementary treatment

What organisation does the complementary treatment professional belong to?

Please explain how this treats the condition.

H. The attending vet or a person authorised by the vet must fill in and sign this section

Please advise the cost of treatment incl. VAT

Condition 1

Condition 2

I declare to the best of my knowledge and belief, that all information provided in this claim form is true and complete.

The fees I have charged are no more than the fees I would normally charge my clients.

Veterinary Surgeon’s Signature:

Date:

Printed Name:

Email address of the Veterinary Practice:

Practice Stamp

Postcode:

IMPORTANT: Please ensure that a dated and itemised breakdown of all treatment costs is attached to the claim form before you send it to us. This must state fees for consultation, prescription charge, hospitalisation, X-rays, tests/pathologies, general anaesthetic, surgery, medication and any other fees and costs must be clearly itemised for each condition.

Tesco Pet Insurance is arranged, administered and underwritten byRoyal & Sun Alliance Insurance plc. Registered in England andWales (No. 93792) at St. Mark’s Court, ChartWay, Horsham,West Sussex, RH12 1XL. Authorised bythe Prudential Regulation Authorityand regulated bythe Financial Conduct Authorityand the Prudential Regulation Authority.

Tesco Personal Finance plc. Registered in Scotland, registration no. SC173199. Registered office: Interpoint Building, 22 HaymarketYards, Edinburgh EH12 5BH.

 

Authorised bythe Prudential Regulation Authorityand regulated bythe Financial Conduct Authorityand the Prudential Regulation Authority.

Tesco Pet Claim Form 453340CU UNFOLDED (09-13)

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