Ontario Spca Pet Insurance Gift Claim Form printable pdf download

gIFT POLICY

CLaIm FOrm

POLICY Number:

POLICY Name:

Official insurance of Ontario’s pets

adOPTed FrOm:

Please forward the completed claim form

POLICYhOLder CheCkLIsT:

and paid invoices to:

Attach detailed paid invoices for condition(s)

Make sure Policy Number is filled in.

Ontario SPCA Pet Insurance , 710 Dorval Drive, Suite 400

being claimed.

Review Policy Documents and Terms

Oakville, ON L6K 3V7 • Toll-Free: 1-866-600-2445

Complete Claim Form fully - both Part1 and Part 2.

and Conditions to see if coverage is available

for the current condition being claimed.

Fax: 1-866-368-7387 •

Attach medical history, if not previously submitted.

Part 1

–

must be completed by the policyholder (please print)

Please check if there has

been a change of address:

Please refer to your Policy Terms and Conditions for the time limitation on submitting claims.

Policyholder:

Address:

City:

Province:

Postal Code:

Telephone:

Fax:

E-mail:

Pet’s Name:

Species:

Age:

Sex:

Male

Female

Breed:

To the best of my knowledge, the following statements are true in every respect and I have abided by all of the Policy Terms and Conditions.

I understand that any misrepresentation or omission of any material fact can result in denial of the claim.

Signature of Policyholder: ___________________________________________________ Date: ____/____/_____ (mm/dd/yy)

Part 2

– must be completed by the Veterinary Clinic ONLY

Please indicate the named accident or illness which was diagnosed and treated:

Foreign Body Ingestion Removal:

Motor Vehicle Accident:

Tick Borne Diseases:

Upper Respiratory Tract Infection:

Heartworm Disease:

Insect Bites/Stings:

Urinary Tract Infection (including FLUTD):

Ear Illness (specify): ____________________________

Lacerations:

Defined Poison Ingestion (specify): _______________

Mange/ Mites/ Ringworm:

Bone Fractures:

Intestinal Parasites (specify): _____________________

Parvovirus/Feline Panleukopenia:

Eye Illness (Specify): ____________________________

Flea Allergy Dermatitis:

Comments:_____________________________________________________________________________________________________________

Date accident occurred or symptoms of illness were first noted: _____/_____/_____ (mm/dd/yy)

Has this pet received treatment for this Illness/Accident in the past?

Yes

If YES, when? :_____/_____/_____ (mm/dd/yy)

Pet’s Weight:

Body Condition Score (BCS):

1-5 Scale (1 = emaciated, 5 = Obese)

Lbs

1-9 Scale (1 = emaciated, 9 = Obese)

Was this accident or illness fatal?

Yes

If claiming for Accidental Death Benefits, please include a statement from a witness or attending veterinarian and a receipt for the original purchase price of the pet.

Please refer to the Policy Terms and Conditions for further details.

Has this pet had an annual physical examination in the past 12 months, and up to date on all recommended vaccinations?

Yes

How long has this pet been a client of your clinic?

Less than 12 months

More than 12 months

Practice StamP

I confirm that to the best of my knowledge, the above statements are true in every respect.

Name of Veterinarian: ______________________________________________________________

Signature: ___________________________________D.V.M.

Date: ____/____/_____ (mm/dd/yy)

Ontario Spca Pet Insurance Gift Claim Form

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