Veterinary fees claim form - The Co-operative Insurance

For official use onlyClaim Form for Veterinary Feesplease make sure this claim form is completed clearly andIN FULL TO ensure the correct assessment of your claim. pleaseComplete a separate form for each pet.Please COMPLETE using A black pen AND block capitals.We’re happy to help!If you have any questions call us on0845 075 45831. Policyholder to complete POLICY NUMBER2. Policyholder to complete ABOUT YOUPolicyholder’s addressPolicyholder’s nameDaytime telephone noEmail addressPostcodePlease tick here if this is different to theaddress on your Certificate of Insurance3. Policyholder to complete ABOUT YOUR PET Male FemalePet’s date of birth / /Pet’s nameIs your pet insured with any other company?YesNoPedigree nameIf Yes, please state which companyIs your pet a Dog CatBreed4. Policyholder to complete DETAILS OF YOUR PET’S CONDITIONDid the illness or injury result in the death of your pet?YesNoWhat condition(s) are you claiming for?Date of death / /Condition 1Please tell us the name and address of veterinary surgeries where your pet hasbeen registered before (If there is more than one, please use a separate piece of paper)Condition 2NameAddressFor each condition, please tell us the date you noticed any signs that yourpet was unwell before booking an appointment with your veterinary practiceYour claim may be delayed if we do not have this informationPostcodeDate / / for Condition 1Date / / for Condition 2Telephone noDate: from / / to / /5. Policyholder to complete PAYEE DETAILSCheques will be automatically made payable to the policyholder named on yourCertificate of InsurancePLEASE COMPLETE ONE OF THE FOLLOWINGPlease note we will not pay your vet unless we have previously agreed withthem to do so. Please check with your vetA. Pay Vet - please tickI have checked with my vet and would like this claim paid directly to themPlease write the name of the veterinary practice hereB. Pay Policyholder - please tickI wish the claim to be paid to the policyholder named on theCertificate of InsurancePlease sign here7Please sign here7Are you happy for us to provide the veterinary practiceidentified on this form with information about yourpolicy in respect of this claim?YesNoI confirm that I have checked the information on this claim form and that itis all correct to the best of my knowledge and beliefImportant notes• The insurance is provided by Allianz Insurance plc.• Please ensure you retain a copy of this claim form and any receiptsfor your records.• Please use a separate claim form for each pet.• Please send completed forms, including copies of all receipts to:Pet Insurance from The Co-operative Insurance, Great West House (GW2),Great West Road, Brentford, Middlesex TW8 9DX.Calls may be monitored and recorded for security or training purposes.The Co-operative Insurance is a trading name of CIS General Insurance Ltd which is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority andthe Prudential Regulation Authority. Registered Office: Miller Street, Manchester M60 0AL. Registered in England Number 29999R. Pet Insurance from The Co-operative Insurance is provided,underwritten and administered by Allianz Insurance plc. Registered Office: 57 Ladymead, Guildford, Surrey GU1 1DB. Allianz Insurance plc is authorised by the Prudential Regulation Authorityand regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Financial Services Register No. 121849. CIS General Insurance Ltd is not part of the Allianz (UK) Group.incomplete Claim FORMS will be returned to THE POLICYHOLDER5042 Co-Op Vet Fees CF 8123-3.indd 1 24/02/2014 14:27

ASK your vet to complete these THREE sections6. Vet to completeGENERAL INFORMATIONWhen was this pet first registered at your practice? / /If this pet has been referred please give the name, address and telephonenumber of the practice which referred itNameAddressTelephone noIn connection with treatment claimed did you:If Yes, were the pet’s vaccinations up to date at time of treatment?Please give dateYes of last vaccination / / No Don’t knowIs any part of this claim for dental treatment?If Yes, please enclose a full clinical history over the last 2 years. If this is notattached this will delay the client’s claimIs any part of this claim for treatment of a urinary problem?If Yes, is the cost of diet food included in this claim?If Yes, please provide the name of the diet food being used and total costbeing claimedYesYesYesNoNoNoMake a house visit?YesNoNameAmount £ -Or provide out of hours treatment?YesNoWere crystals present?YesNoIf Yes, why was the house visit/out of hours treatment necessary?If Yes, are the crystalsIf other, please specifyOxalate Struvite OtherPlease give dates and results of last two urine testsDate / / ResultIs any part of this claim for a condition the pet can bevaccinated against?YesNoDate / / Result7. Vet to complete ABOUT THE ILLNESS OR INJURYCondition 1Name of the illness or injury (if no diagnosis has been made please give clinical signs)7. Vet to complete ABOUT THE ILLNESS OR INJURYCondition 2 (If relevant)Name of the illness or injury (if no diagnosis has been made please give clinical signs)Is this claim a continuation?YesNoIs this claim a continuation?YesNoWhen did this illness or injury begin (as noted on your records)? / /When did this illness or injury begin (as noted on your records)? / /Treatment dates:from / / to / /Treatment dates:from / / to / /Did death or euthanasia result from this illness or injury?YesNoDid death or euthanasia result from this illness or injury?YesNoDate of death / /Date of death / /If the pet was put to sleep, did you recommend this?YesNoIf the pet was put to sleep, did you recommend this?YesNoTo your knowledge has this pet been seen before for:To your knowledge has this pet been seen before for:This illness or injuryYesNoThis illness or injuryYesNoAny similar or related illness or injuryYesNoAny similar or related illness or injuryYesNoAny similar or related clinical signsYesNoAny similar or related clinical signsYesNoIf Yes, please provide the history with dates?If Yes, please provide the history with dates?Date / /Date / /Date / /Date / /Total amount claimed (inc VAT)£ -Total amount claimed (inc VAT)£ -Please enclose full invoices to support this claimPlease enclose full invoices to support this claim8. Vet to complete DECLARATION BY THE VETERINARY PRACTICEVet stampThis practice is authorised to have claims paid directYesNoI have checked the information on this claim form and confirm that it is all correctto the best of my knowledge and beliefNamePosition in practiceEmail addressSignature7Date / /incomplete Claim FORMS will be returned to THE POLICYHOLDER 8123/3 03.145042 Co-Op Vet Fees CF 8123-3.indd 2 24/02/2014 14:27