Claim Form - Vetsure (Page 2 of 3) in pdf

Section 2

This section to be completed by the Veterinary Surgeon

Age of pet:

How long have you been treating the animal?

If this is a referral, please advise of the practice name and address that referred the case:

Date

Diagnosis

Treatment

Cost (inc. VAT)

Has the animal received treatment for any of the above, or any related conditions before?

YES/NO

If yes, please provide details:

Delete as appropriate

Is this a continuation claim?

YES/NO

Delete as appropriate

Do you consider this to be a hereditary/congenital condition?

YES/NO

Delete as appropriate

If a home visit was made, was it because moving the pet would have endangered the

YES/NO

pet's health?

Delete as appropriate

Has the pet died as a result of the illness/injury mentioned above?

YES/NO

Delete as appropriate

If the claim payment is a direct settlement to be paid straight

Practice account name

into the Surgery bank account by BACS (Bankers Automated

Sort code

Clearing Services) please provide the details here.

Account number

If a direct settlement is instructed and no bank details are provided, claim payment will be made by cheque

Declaration by Veterinary Surgeon:

Veterinary Practice Stamp and VAT No:

I certify that, to the best of my knowledge all the information contained on this form

is correct and that, in my opinion, the condition treated would not have been

present upon the date of the inception of the policy. I also confirm that, in my

opinion, the fees charged are my normal practice fees relating to this matter.

Signed

Date

Practice email address

Print name

A FULL CLINICAL HISTORY AND AN ITEMISED RECEIPT OR ACCOUNT MUST BE ENCLOSED FOR

VETERINARY FEE CLAIMS

Pet Doctors pet insurance is a trading name of TVIS Ltd whose company registration no. is 06820979 and registered address is 2nd Floor Titan Court,

3 Bishop Square, Hatfield, Hertfordshire, AL10 9NA. TVIS Ltd is authorised and regulated by the Financial Conduct Authority (FCA no.523215).

Policies are underwritten by Atlas Insurance PCC Limited transacting for its TVIS Cell. Atlas Insurance PCC Limited is a cell company authorised by

the Malta Financial Services Authority to carry on general insurance and is a member of the UK's Financial Services Compensation Scheme.

Registered in Malta at Xbiex Seafront, Ta' Xbiex XBX1021, Malta. (Company Registration no. C 5601).

Claim Form - Vetsure Page 2

Related Articles

Related forms

Related Categories