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Claim form for Veterinary fees, Contacting Petplan Equine
Death, Permanent loss of use If you have any questions, call:
For Petplan Equine use only &�1300 791 311
www.petplan.com.au
You can use this form to claim for
up to two separate illnesses or injuries.
1 About you IMPORTANT NOTES
• Administer
Your name • Goulburn Valley Insurance Brokers
Please tick here if this is new administer the policy on behalf of
Your address and postcode and different to the address
on your certi?cate of insurance. Farmers Mutual Insurance plc
who underwrites the policy
If you are GST rated please supply • If claim is being faxed please
your GST number.
retain all the original copies
Daytime phone number
of claim form and receipts
e-mail address • Please include all required
documentation - see note
Your policy number
in column below for
further details
2 About your horse • Please use one claim
form per animal
Your horse's name Age
• CLAIMS RECEIVED THAT
Colour Height ARE INCOMPLETE OR
MISSING INFORMATION
Sex Stallion / Colt Mare / Filly Gelding
WILL BE RETURNED
Are you the only owner TO YOU
Yes No Tell us who else shares ownership on a separate sheet
of the horse?
• Please send the
Have you any other insurance No Yes Tell us the details on a separate sheet
for this horse? completed form to :
Was anyone else responsible for Petplan Equine
No Yes Tell us the details on a separate sheet
your horse when it was injured 28 Garden Drive
or became ill?
Tullamarine
Name and address of your usual Name Victoria
veterinary practice
Address
3043
Tel No.
or fax: (03) 9339 3355
3 About your claim You will need to enclose
the following documents
What are you claiming for?
with your claim form
Have you claimed for These need to be the
Vets fees Yes this condition before?
No Continue to complete claim form
original documents
Yes Claim ref. no.
Vets fees
If you claimed for this illness or injury before please tell
us the claim number and go to section 4
Veterinary invoice(s)
Permanent loss of use Yes
Invoice(s) for any
Death / Humane destruction Yes When was the horse destroyed or when did it die? date
alternative treatment /
time am / pm corrective shoeing
Disposal costs Yes Permanent loss of use
Vets clinical history report
Give details of the injury Please give precise details of the
part of the body affected and
or illness attach a separate sheet if you Evidence of ownership
need more space
Death
What was the horse being used
for at the time? Post mortem report
Where did the injury happen (Unless we tell you this
or the horse first become ill?
is not required).
If there was a delay of more than
When did this happen? time am / pm date 24 hours before the vet attended Disposal receipt
please advise the reasons behind
this on a separate sheet of paper
When was the vet first called? time am / pm date Evidence of ownership
Are you claiming for the cost If YES, how much does your Vets clinical history report
No Yes shoeing normally cost?
$ per set
of correct shoeing?
NOW PASS THIS FORM TO YOUR VET AND ASK THEM TO COMPLETE SECTIONS 4 - 7 AND RETURN THE FORM TO YOU
ON RECEIPT OF THE RETURNED FORM PLEASE COMPLETE SECTION 8 AND SEND THE FORM TO PETPLAN EQUINE
4 About the injury or illness (for the vet fill in)
Did the horse die due Yes No A post mortem must be carried out unless we have advised this is not required
to this injury or illness?
Was the horse euthanised Yes No
due to the injury or illness?
Did the horse's condition meet Yes No
the guidelines set by AVA for
immediate destruction?
Illness or injury 1 Illness or injury 2
Diagnosis of the
illness or injury
Or give the clinical signs if you
have not yet made a diagnosis.
Please indicate the exact areas affected.
If any illness, injury or clinical signs are related, please use a single column If any illness, injury or clinical signs are related, please use a single column
Have you sent us a claim for Yes No or don't know Yes No or don't know
this illness or injury before?
go to section 5 go to section 5
When did this illness date date
or injury first begin?
(as noted by you, by the client
or on the horse's record) Details Details
If the horse has been seen
before for:
• this illness or injury;
• any similar or related
illness or injury; or
• any similar or related
clinical signs; Is the illness or injury being claimed
Yes No Is the illness or injury being claimed
Yes No
for related to this history? for related to this history?
please give us the history with dates
Is the illness or injury likely Yes No Yes No
to need further treatment?
5 Alternative treatment (for the vet to fill in)
Did you recommend any No Yes If YES please detail
No Yes If YES please detail
alternative treatment? treatment recommended treatment recommended
If the horse requires remedial farriery
please advise how many feet this is for Details Details
6 Treatment & fees (for the vet to fill in)
First and last date of treatment First last First last
being claimed for
Please attach detailed invoices listing dates, treatment Please attach detailed invoices listing dates, treatment
and medication for each illness or injury and medication for each illness or injury
7 Declaration (for the vet or a person authorised by the vet to fill in & sign)
I have checked the information Signature Practice stamp
on this claim form and as far
as I know it is correct
The fees I have charged are
X
no higher than my normal fees
date
Is your practice a Petplan preferred
practice?
this may helps us deal with the claim quicker
8 Declaration (for you to fill in & sign after your vet has completed sections 4 - 7)
I claim for the cost of Veterinary practice Other
Myself
treatment covered by my (named opposite) (named above)
policy and agree that you Your signature Your signature
will make any payment if there are two policyholders shown on certifcate of insurance each one must sign if there are two policyholders shown on certifcate of insurance each one must sign
to the person or practice
indicated opposite
X X
date date
Petplan Equine is a registered Trade Mark, Products sold under this Trade Mark in Australia are sold exclusively by Goulburn Valley Ins Brokers under licence to Petplan UK
Limited.
Goulburn Valley Ins Brokers (ABN 64 069 468 542) is authorised and regulated by the Australian Financial Services Licence Registeration Number 245663.
15/07
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