Claim Form Trupanion Pet Insurance by alicejenny


									                                                                                                                                  Claim Form
                                                                                                                                  Fax: 1.866.405.4536
                                                                                                                                  Phone: 1.800.569.7913
       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 #:

       Address:                                                                                Species:
                                                                                                                               Pet's Age:
                                                                                                      Cat      s   Dog
                                                                                                s     Male         Female
                                                                                                                                Spayed/Neutered Date (mm/dd/yy):
       Telephone:                                        Preferred Contact Times:
                                                                                                      Yes          No

                                                                                               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
                                                                                              through present.
       Claim Total:

       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?
             Yes             No

       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
       1.866.405.4536                                  Trupanion
                                                       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
                                                                                              1.800.569.7913                                 1.866.729.2915

rev - 8.11      Trupanion plans are underwritten by American Pet Insurance Company.

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