Claim Form (PDF) by xusuqin


									                                                                  Secure Insurance Claim Form

So that we can process your claim as quickly and accurately as possible, please complete this form clearly and in full.

This section to be filled out by the Policy Holder:

Policy Holder's Name:                                                                   Council Rego Number:

Policy Holder's Address:                                                                Email:

                                                                                        Pet's Name:                                          D.O.B            /         /

State:                                   Postcode:                                      Breed:                                               Colour:

Tel (H):                                 Tel (W):                                       Dog                      Cat                  Male                   Female

Tel (Mob):                                                                              Desexed                  Yes                    No

Date you first noticed any signs Pet was unwell                                         Name of treating Vet

Describe in your own words what happened:                                               Address


                                                                                        Telephone                          Date of treatment from:                to:

                                                                                        Is anyone else or their pet responsible for the injury or illness:   Yes / No       Please circle

                                                                                        If yes please supply name and address of the person and why you believe them to

                                                                                        be responsible:

This section to be fillout by the Vet

Please describe the Pet's illness or injury and the treatment that was carried out

Is any part of this claim for a condition the pet can be vaccinated against? Yes / No              Were the pet's vaccinations up to date at time of treatment? Yes / No

Has this pet been seen previously for:        this injury or illness? Yes / No       related injury or illness? Yes / No         Similar or related clinical signs? Yes / No

If answered Yes to any of the above three questions please provide further details:

Did death or euthanasia result from this injury or illness? Yes / No                 If the pet was put to sleep could it otherwise have been treated? Yes / No

I/We cerify that the information given in this form is accurate, truthful and complete and that no information likely to affect this claim has been withheld. I/We authorise
any Veterinary Surgeon who has treated my/our pet to provide the insurer any details they may require. Please note that issuance or completion of this form does not
acknowledge liability or guarantee payment of the claim. I/We understand that this claim may be refused if information is untrue, inaccurate or concealed.

Signature of Policy Holder:                                                          Print Name:                                                  Date:
Signature of Veterinarian:                                                           Print Name:                                                  Date:

Please attach your Pet's complete veterinary history (medical) from both current and previous veterinary clinics.

Please attach full itemised invoices and receipts to support this claim

Scan and email the claim form and the attachments to

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