Part A :: To be completed by pet owner
IMPORTANT: We want to respond to your claim as quickly as possible so please fill out ALL information below as well as attaching:
1. Your pet’s medical records from all previous and current veterinary or emergency clinics 2 years prior to enrollment through
present. (Unless you have provided the history previously, then just any new medical history.)
2. A copy of your veterinarian’s itemized invoice or an official pharmacy receipt.
Name: Pet's name: Policy #:
Cat s Dog
s Male Female
Spayed/Neutered Date (mm/dd/yy):
Telephone: Preferred Contact Times:
Has your pet been to any other vets prior to enrollment?
Email: Yes No
Please list all veterinary hospitals visited 2 years prior to enrollment
I understand I am financially responsible to my veterinarian for the entire treatment. I understand that this claim may not be covered or may exceed my plan benefits.
I authorize my veterinarian(s) to release my pet’s medical records to Trupanion. Claims must be submitted for processing within 90 days of treatment or service.
Your signature Date (mm/dd/yy)
Part B :: To be completed by attending veterinarian
This pet required care due to an: FOR VETERINARIAN USE ONLY
Illness Accident/Trauma Process as Claims ExpressTM (direct payment to the veterinarian)*
Date of injury OR when illness first appeared (mm/dd/yy): Type and cause of injury OR illness diagnosis:
Has this pet been seen by another vet clinic? If yes, which clinic?
Practice Stamp or Printed Name & Number of Clinic:
Has the pet owner been following your recommended routine care program?
I confirm to the best of my knowledge the above statements are true in every aspect.
Signature of attending veterinarian Print name Date (mm/dd/yy)
Part C :: Claim submission
By toll free fax: By mail: *Claims ExpressTM
907 NW Ballard Way
A great way to better serve pet owners - have us pay you directly!
Call and ask about a pre-approval: Claims ExpressTM fax only:
Seattle, WA 98107
rev - 8.11 Trupanion plans are underwritten by American Pet Insurance Company.