Claim Form For Veterinary Fees - Co-Op Insurance
ADVERTISEMENT
1
2For official use only
Claim Form for Veterinary Fees
Are you completing this form for a:
Co-op Insurance,
We’re happy to help!
Great West House (GW2),
New illness or injury
Complete ALL sections clearly and in full.
If you have any questions call us on
Great West Road,
0345 075 4583
Continuation illness or injury
Brentford, Middlesex
Complete sections shaded blue only.
TW8 9DX
Please complete using a black pen and block capitals. Missing information will delay your claim.
If this is the first claim for this pet, please can you submit a full clinical history. Ask your vet to complete these three sections
1. Policy Number
Policyholder to complete
2. About You
3. About your pet
Policyholder to complete
Policyholder to complete
Policyholder’s name
Pet’s name
Daytime telephone no
Pedigree name
Email address
Breed
Policyholder’s address
If crossbreed, please state dominant breed
(Dogs only)
Pet’s Microchip no.1
Pet’s Microchip no.2
Pet’s date of birth
/
/
Male
Female
Postcode
Which date did you take ownership of your pet?
/
/
Please tick here if this is different to the address on your Certificate
If this is the first claim you are submitting for your pet you must include
of Insurance. Your policy records will be updated with these details.
a full clinical history from all of the vets that your pet has been registered
with, plus any information you may have from the person/party you
obtained your pet from. Your claim will be delayed if this is not included.
4. Details of your pet’s illness/injury
Policyholder to complete
For each condition you are claiming for, please tell us the date you first
Condition 2
noticed any signs that your pet was unwell or injured. This date may be
Date you noticed your pet was unwell
/
/
before you contacted your veterinary practice.
Description
Your claim will be delayed if we do not have this information.
Condition 1
Date you noticed your pet was unwell
/
/
Description
Did the illness or injury result in the death of your pet? Yes
No
Date of death
/
/
Please give us details of ALL other veterinary practices that your pet
has been registered with on a separate piece of paper.
5. Payee details
Policyholder to complete
Please complete one of the following
7
Please sign here
Please note we will not pay your vet unless we have previously agreed with
them to do so. Please check with your vet.
Pay the vet direct – please tick
I/We have checked with the vet and would like this claim paid directly to them
Print name
Date
/
/
Practice name
By signing this form I authorise Allianz Insurance to provide the veterinary
practice with information about my policy in respect of this claim and the
Pay policyholder(s) by Cheque – please tick
veterinary practice to provide Allianz Insurance with all information relating
to my pet. I also confirm I have checked the information given on this form
I/We wish the claim to be paid to the policyholder(s) named on the
and that it is correct to the best of my knowledge.
Certificate of Insurance
ADVERTISEMENT
0 votes
Related Articles
Related forms
Form M-36 - Combined Claim Form For Refund Of Fuel Taxes Liquid Fuel (gasoline) Used For Agricultural Equipment Operated Off Public Highways, Diesel Oil Used For Motor Vehicle Operated Off Public Highways, And Alternative Fuel Used For Motor Vehicle And I
Financial
Related Categories
Parent category: Legal