Transcription of Claim Form - Vet Fees - Agria Pet
1 Claim form - Vet FeesTo be compl eted by the policyholder and veterinary surgeonAll sections must be fully completed and supporting documents supplied or we may notbe able to proceed with your claimy Py k if Poli cAbout la imsy sx v yy vy pet?Is yvy y insurance ss smy my mrm ys vy first f PP f fsss Poli cPtion yr srrmm y rm yms mry yr mk r ymrvk r yr rmm sy r y rrrymk srvsr into sssrs s kr s my rsyr m rrrsrv rrsrr sm mym vmy srsvsm srr rs vy my rr mrsP yall ouaelaiellin e onsk yr y Bkr s s sv rrr y r sy rs ms sfi yr s rrs rm r yr vrry s rsm s r v rsPA sry ( r ms v r )A rs r ( r ms r fi ) Agria Pet Insurance Limited, PO Box 506, Manchester M28 8 ENtion Sry s my krmsrm srrfi rm srr my rmrs rsmrrsssssrm mmsm rmy Surgs5.
2 Vet to completeDetails of long has this pet been registered at the practice? If this pet is less than 2 years of age please confirm the dates of the primary vaccination course. / / / / If this is a referral case please provide the name, address and telephone number of the referring practice and attach a copy of your report on the from Date toDiagnosis Clinical symptoms Costs ( ) (inc. VAT)When did the policyholder first notice any signs or symptoms of the pet s illness / injury? Date / / the pet received treatment for any of the above, or any related illnesses or injuries or clinical signs previously?
3 YesNo(If Yes, please provide details and use a separate sheet if necessary quoting the policy number in the top right hand corner)Is this a continuation Claim ? any of the fees in respect ofpre-operative blood tests? YesNo Are any of the fees in respect of house visits / ambulance fees ? YesNoIf Yes, were these essential in the interests of the pet s health? YesNoIf yes, please advise whether the pet s health would have beenseriously endangered if moved? any of the fees for a prescription diet? YesNoName of diet the Claim include fees for any of the following treatments orPl ease provide full details of t he person or hydrotherapy pool where the pet was referredtherapies: herbal orhomeopathic medicine, physiotherapy, osteopathy,chiropractic, hydrotherapy, acupuncture or behavioural?
4 YesNoIf yes, please answer the following questions. Please provide the dates of treatmentWhat type of treatment or therapy has been provided?Number of hydrotherapy sessions providedPlease confirm that this treatment or therapy was recommendedby the treating veterinary surgeon YesNoTotal cost of treatment / therapy PLEASE RETURN WITH THE APPROPRIATE SUPPORTING DOCUMENTATION TO:Veterinary PracticeStamp:s s rsss ry mvs s r mr rmrs y ys mAgria Pet Insurance Limited,Telephone 01296 611604 Facsimile 01296 422650 Website: Helpline 03330 30 83 99 Agria Pet Insurance Limited is authorised and regulated by the Financial Conduct Authority.
5 Vet please notePO Box 506, Manchester M28 8EN
