Pet Healthcare Claim Form - Jeffersonville, Indiana Claims Department

Easy!

Filing a claim is

1. Complete the claim form below.

6. Send the completed claim form and receipt(s) to:

MAIL:

2. If filing an accident or illness or routine care coverage claim,

Claims Department

record the diagnoses and treatment date for your veterinary

One Quartermaster Court

visit. If filing a supplemental benefit claim, record the details

Jeffersonville, IN 47130

and receipt date.

EMAIL:

3. Sign and date the form where indicated.

FAX: 877-281-3348

4. Have your veterinarian sign and date the form where indicated

if claiming accident or illness or routine care coverage.

All claims must be submitted in writing within ninety

(90) days of the treatment or receipt date.

5. Include the original itemized receipt(s) for treatment or

services. Retain a copy for your records.

Effective Date: _______/_______/_______

Policy Number: ______________________

Expiration Date: _______/_______/_______

Plan: ____________________________________________________

Pet Name: ___________________________

Name: ____________________________________________________

Species: r Dog r Cat

Address: __________________________________________________

Color: ___________ Breed: _____________

City: ________________________ State: ________ Zip: _____________

Sex: r Male r Female Age: _________

Phone: _______________________________________

PLEASE COMPLETE BELOW. INCOMPLETE FORMS WILL DELAY CLAIMS PROCESSING.

You must provide a copy of the medical records pertaining to this incident. If this your first claim specific to this incident, please provide a copy of your pet’s written medical records for the last twelve (12) months.

Accident, Illness or Routine Care Coverage Claim

:

(Please Print)

/

/

$

Treatment Date

Medical Diagnoses or Routine Treatment

Total Charges

/

/

$

Treatment Date

Medical Diagnoses or Routine Treatment

Total Charges

/

/

$

Treatment Date

Medical Diagnoses or Routine Treatment

Total Charges

/

/

$

Treatment Date

Medical Diagnoses or Routine Treatment

Total Charges

Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially

false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the

person to criminal and civil penalties.

Veterinary Clinic

Name, Address, and Telephone

Policyholder Declaration

I declare my veterinarian recommended the treatment for which I am claiming. The particulars given are

correct to the best of my knowledge and belief. I authorize my veterinarian to release medical records

and give consent to PetFirst Pet Insurance to communicate with my veterinarian or veterinarian’s staff.

/

/

X ____________________________ _____________

Policyholder Signature

Date