Claim Form - Pets Best

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Claim Form
HOW TO FILE YOUR CLAIM:
1. Please read and complete each section of the claim form
Please do not:
2. Be sure to sign the claim form
 Staple your forms
3. Include itemized invoices that show proof of payment
 Write on your invoices
*please note: Estimates, Open or Unpaid invoices cannot be processed
 Highlight your invoices
4. Submit your claim by fax, online upload, or mail
 Cover your invoices
5. Packages MUST be itemized
1
TREATMENT INFORMATION
Questions? Please call 1-877-738-7237.
Pet Name:
Policy Number:
 Urinalysis
 Blood Panel
 Wellness Exam
Are you claiming any of these items under your BestWellness?
 Yes
 No
Have you submitted a claim for this condition before?
Diagnosis Section
Why did you take your pet to the veterinarian? (Please list the diagnosis if known)
Additional history or notes
2
YOUR INFORMATION
 Please check here if your information has changed
Name:
Phone:
Email:
Address:
City:
State:
Zip:
3
POLICYHOLDER DECLARATION
I confirm to the best of my knowledge that all statements provided on this form are true. I hereby give Pets Best authorization to request any
and all medical records or financial information for the claimed pet and authorization to discuss the details of this claim with the treating
veterinarian or their authorized representative.
FRAUD WARNING: I certify that I have read and understand the applicable Fraud Warning listed on page 2 of this form.
X
Policyholder Signature is required (electronic signatures are not accepted)
Date
4
SUBMIT YOUR CLAIM
If you would like reimbursement sent directly to your veterinarian, please log in to your customer account at
to print off
and attach a filled out Veterinary Reimbursement form with this claim. If you have any questions, please call 1-877-738-7237.
ONLINE UPLOAD
MAIL
FAX
/customerportal
2323 S. Vista Ave., Suite 100
866-777-1434
Boise, ID 83705
Insurance plans offered and administered by Pets Best Insurance Services, LLC are underwritten by Independence American Insurance Company (IAIC).

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