Claim_Form

							                                                                          PET INSURANCE CLAIM FORM
                                                                          NO COVER SHEET NECESSARY. Fax to: 714-989-5600

                                                                                                                        No. of pages:
 1

POLICY NO:                                                                NAME:

PET NAME:                                                                 ADDRESS:

BREED:                                                                    CITY:

AGE:                                                                      STATE:                           ZIP:

                                                                          PHONE:

                                                                          E-MAIL:


 2
                              DIAGNOSIS(ES)                                            TREATMENT                         HOSPITAL/
     Ask your veterinarian to provide a diagnosis, or a tentative diagnosis.              DATE                            CLINIC


                                                                                          /       /
                                                                                          /       /
                                                                                          /       /
                                                                                          /       /

 3        TOTAL AMOUNT SUBMITTED

                                                                               You must submit receipts for all veterinary service charges.
         $                                                                     All submitted fees may not be eligible for coverage. Fees that
                                                                               exceed coverage form limits are your responsibility.



 4       POLICYHOLDER SIGNATURE and DATE

                                                                               By signing this Claim Form, I confirm that to the best of my
        X                                                /     /               knowledge the information I have provided is true and correct.
                                                                               I authorize the release of my pet’s medical records to Nationwide
                                                                               Pet Insurance.


 5       SUBMIT CLAIM FORM and INVOICE(S)                                                                               CLAIMS NOTES




       FAX: 714-989-5600 (Preferred Method)
       Or by MAIL:
       Nationwide Claims Department                                        DOCUMENT CENTER USE ONLY

       PO Box 2344, Brea CA 92822-2344

          PLEASE DO NOT USE STAPLES, PAPER CLIPS OR TAPE
             to attach receipts or invoices to your claim form.


       NCF-1(07-11)                                           11RET1449
FAX ONLY THE FRONT PAGE OF THIS CLAIM FORM. NO COVER SHEET IS REQUIRED.




     Claim Form Check List
            r       My claim form shows my name, my pet’s name
                                                                                                            P
                    and my pet’s policy number.
            r       The diagnosis box has been filled in with my
                    pet’s injury or illness.
            r       I have included my itemized invoice,
                    which shows my pet’s name.


          Have claim forms handy when you need them. Keep extra copies:
                                  P	 home, with other pet-related documents
                                   At
                                  P	 your glove compartment
                                   In
                                  P	 file at your veterinarian’s office
                                   On



                        Fax OR Mail Your Claim:
                              Fax: 714-989-5600
                                                            OR
 Mail: Nationwide Claims Dept., PO Box 2344, Brea, CA 92822
                            Please submit your claim via only one method.
                          Duplicate claim submissions may delay processing.




Pet insurance underwritten by Veterinary Pet Insurance Co.(CA); National Casualty Co.(states outside CA), both Nationwide-
affiliated companies. Home Office: Brea, CA. Subject to underwriting guidelines, review, and approval. Products and discounts
not available to all persons in all states. Nationwide, Nationwide Insurance, and the Nationwide framemark are service marks of
Nationwide Mutual Insurance Company.