Pet Claim Form - Vet’s Fees (Continuation Claim)

1 Pet Claim form - Vet s fees (Continuation Claim )Policy No:Date Issued:1 Your DetailsYour NameAddressDaytime Tel. Tel. Your Pet s DetailsName of petType of petAge of petYOUR VETandCompletes sectionThorpe Underwood HallOuseburn, York, YO26 9 SSTel: 08449 809 400 Fax: 08449 809 410email issue of this form doesnot constitute an admissionof Claim liability by E&L .REQUIREMENTSP lease ensure that allsections are completed byyou and your vet form must be returned tous at the address shownbelow within 90 days. Emailof Fax copies of the claimcan be sent 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 will be issued toYou unless otherwiserequested. You can selectan alternative payee byticking the relevant box onthe Claim form You fill in andby providing the third OF RIGHTSE&L reserve the right toappoint loss adjusters orveterinary consultants toreview the Claim and also torequest further informationfrom current or previous vetsor previous will have to pay your vetthe excess and anyunrecoverable items costs, Claim formcompletion costs vetpracticePostcodeNameAddressEmail123(T his section to be completed by the policyholder)(This section to be completed by the policyholder)

2 Claim FORMS RECEIVED WHICH ARE INCOMPLETE WILL BE RETURNED TO THE of petDate of purchasePrice paid Sex of petMaleFemaleYOU Complete sectionsIMPORTANT NOTESREQUIREMENTSC ontacting UsIf you have any queries, please call08449 809 400 Mobile hereby declare that the details given by me, are to the best of my knowledge, true and authorise the vet to provide, upon request, all copies of medical records of pets treated on my s SignatureDateDeclaration(This section to be completed by the attending vet)Date of deathIn the event of deathplease advise of:Cause of deathName of pet3 Details of Condition and Treatments Given (This section to be completed by the attending vet)Age of petHow long has your practice known this pet?What were the clinical signs / your diagnosis?yearsFromCostTo(inc. VAT) If the pet was put to sleep, please indicate why:If the animal was presented at an out of hours surgery, or subject to ahome visit, was the condition life endangering?

3 YesNoIs it likely the condition suffered will require further treatment/medication?YesNoIf YES, is it likely the condition suffered will require treatment/medicationfor the rest of this pet s life?YesNoIf NO, once treatment/medication has ended is this pet at a higher risk ofthe condition reoccurring than a pet which has never suffered it before?YesNoThe RCVS regard an insurance Claim form once signed by a vet as being a veterinary certificate with attendant serious hereby certify that I have checked the information in Section 3, and that to the best of my knowledge it is correct. The fees I have chargedare no higher than my normal practice s SignatureDateDeclaration(This section to be completed by the attending vet)Practice NameVet s NamePractice AddressMRCVS/FRCVS(Please ensure all relevant invoices areattached)MeThirdPartyIn the event of vet s fees payment becomingdue, to Whom should payment be made?NameCD4 YesNoCould this Claim potentially be coveredunder any other policy of insurance?

4 IfYes, please provide full schemes are underwritten by the Equine & Livestock Insurance Co Ltd (E&L ) which is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and thePrudential Regulation Authority no. 202748. This can be checked by visiting the FCA s website or by contacting the FCA on 0800 111 6768.