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Pet Claim Form - DeathPolicy No:
Date Downloaded:
1 Your Details
Your Name
Address
Daytime Tel. No.
Evening Tel. No.
Postcode
2 Pet’s Details
Name of pet
Type of pet
Age of pet
YOUR VET
and
Completes section
Thorpe Underwood HallOuseburn, York, YO26 9SS
Tel: 08449 809 639Fax: 08449 809 410
email [email protected]: www.pet-insurance.co.uk
LIABILITY
The issue of this form doesnot constitute an admissionof claim liability bypet-insurance.co.uk
REQUIREMENTS
Please ensure that allsections of the claim form arecompleted by you and yourvet as indicated. Pleaseensure that your vetincludes your pet’s medicalhistory with the claim form.The form must be returned tothe address shown belowwithin 90 days. Email or Faxcopies of the claim can besent in advance.
SETTLEMENT
In the event of claimssettlement becoming due Wewill issue settlement byBACS transfer. Where bankaccount details have notbeen provided or this is notpossible, settlement will bedespatched by cheque.Settlement will be issued toYou unless otherwiserequested. You can select analternative payee by tickingthe relevant box on the claimform You fill in and byproviding the third partyname.
RESERVATION OF RIGHTS
Pet-insurance.co.uk reservethe right to appoint lossadjusters or veterinaryconsultants to review theclaim and also to requestfurther information fromcurrent or previous vets orprevious insurers.
EXCESS
You will have to pay your vetthe excess and anyunrecoverable items E.G.Admin costs, claim formcompletion costs etc.
Dog Cat
Attending vetpractice
1 2
3
(This section to be completed by the policyholder)
(This section to be completed by the policyholder)
CLAIM FORMS RECEIVED WHICH ARE INCOMPLETE WILL BE RETURNED TO THE POLICYHOLDER.
Breed of pet
Date of purchase Price paid £
Sex of pet Male Female
YOU Complete sections
IMPORTANT NOTES
(Overleaf)
REQUIREMENTS
CONTACTING USIf you have any queries, pleasecall
08449 809 400
Mobile No.
I hereby declare that the details given by me, are to the best of my knowledge, true and complete.I authorise the vet to provide, upon request, all copies of medical records of pets treated on my behalf.
Policyholder’s Signature Date
Declaration (This section to be completed by the policyholder)
Has your pet beenroutinely wormed?
Has your pet beenroutinely vaccinated?
Postcode
Name
Address
Injury, illness ordisease you areclaiming for and thedate you first noticedthe clinical signs.
Claim
TimeDate
** If your pet hasbeen involved in aaccident please usea separate sheet totell us exactly how ithappened.
Practice where yourpet has beenpreviously registered,if applicable.
Postcode
Name
Address
Yes No
Yes No
Has your pet beenneutered?
Yes No
CD3
Me VetIn the event of vet’s fees payment becomingdue, to Whom should payment be made?
Name
Yes NoCould this claim potentially be coveredunder any other policy of insurance? IfYes, please provide full details.
pet-insurance.co.uk is a scheme administered and underwritten by the Equine & Livestock Insurance Co Ltd (E&L®) which is authorised by the Prudential Regulation Authority and regulated by theFinancial Conduct Authority and the Prudential Regulation Authority no. 202748. This can be checked by visiting the FCA’s website or by contacting the FCA on 0800 111 6768.
Other
Pet Claim Form - Death
The RCVS regard an insurance claim form once signed by a vet as being a veterinary certificate with attendantserious implications. I hereby certify that I have checked the information in Section 3 and 4, and that to the best ofmy knowledge it is correct. The fees I have charged are no higher than my normal practice fees.
Vet’s Signature Date
3 Details of Condition and Treatments given. (This section to be completed by your vet)
Declaration (This section to be completed by the attending vet)
Practice Address
Practice Name
Vet Name MRCVS/FRCVS
P.O.Box 100 York, YO26 9ZATel: 08449 809 639Fax: 08449 809 410
email [email protected]: www.pet-insurance.co.uk
To be Completed by YOUR Vet.
PLEASE NOTE THAT IF ANY QUESTIONS ARE LEFT UNANSWERED IT IS LIKELY TO CAUSE A DELAY IN THEASSESSMENT OF THE CLAIM.
Policyholder Name:
Address:
Policy No:
Postcode Tel. No.
Name of pet Age of pet
How long has your practice known this animal?
Please can you provide a copy of the animal’s medical/clinical history for the duration of ownership. If there isno history available please state the reason why (e.g. We are the referral practice/first time the pet had beenseen by this practice):
Illness or Injury - Claim
Please give yourdiagnosis or cause ofdeath.
Dates and Costs oftreatment if applicable.
From
Cost
To
In the case of anillness how long didthe animal have thiscomplaint prior to yourfirst consultation. (As noted by you, stated by the client or on the pet’s record).
Was the animalpresented at an out ofhours surgery, orsubject to a home visit.
Did you refer this animalto another vet?
Yes No
Yes No
Has the pet been seenbefore, for this illness orinjury?
Yes No
If YES, please state the name and address below:
Has the pet been seenbefore, for any similar orrelated illness or injury?
Yes No
Has the pet been seenbefore for any similar orrelated clinical signs?
Yes NoIf YES, please give date and details below:
If the animal was put tosleep, please indicatewhy:
PLEASE NOTE THAT IF ANY QUESTIONS ARE LEFT UNANSWERED IT IS LIKELY TO CAUSE A DELAY IN THE ASSESSMENT OF THE CLAIM.
CD3
