Transcription of Claim Form - 24PetWatch
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Claim Form - 24PetWatch
Complete Section 1 About You and Your Pet Include your Policy Number and Contact Information Review your Policy Documents and Terms and Conditions regarding available coverage and limits applicable to your policyHave the treating veterinarian complete Sections 2, 4 and 3 if Section 3 Payment DetailsSign your Claim form in Section 4: DeclarationsAttach detailed paid invoices for condition(s) you are claiming forContinue to Page 2 Claim FormClaims ChecklistSECTION 1A: Your Pet s InformationSECTION 2: About Your Claim To be completed by the treating licensed VeterinarianSECTION 1B: Your InformationDetailed examination or SOAP notesLab/pathology/radiology reportsMedical reports from referral or emergency hospitalsTransaction histories and invoices are not acceptedDetailed and Itemized indicating the cost and treatmentPaid, unless reimbursement is to be made and agreed to by the veterinarian Account Summaries are not acceptedINSTRUCTIONS: Please complete ALL sections on this form and submit with your paid itemized invoice and pet s medical history.
client or the pet’s medical record) Has this medical condition been ... ˜les an application for commercial insurance or a statement of claim for any commercial or personal insurance bene˜ts containing any materially false information, or conceals ... solicits or conspires with another to make a false repor t of the theft, destruction ...
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