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 Sex: s Male Female Spayed/Neutered Date (mm/dd/yy): Spayed/Neutered: 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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