businesses insurance_PET CARE INSURANCE CLAIM FORM

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					                                                                                                               Customer Service Hotline: 3412 2666
                                                                                                                        (via Distributor)

                                          PET CARE INSURANCE CLAIM FORM
    Please include the itemized invoices and receipts.
    Claims must be notified in writing to Blue Cross (Asia-Pacific) Insurance Limited within 30 days of incident.
    Fax claim notification must be followed by the original document.
    Please do not admit any liability fault or make / offer promise of payment without the Company’s prior written consent.

PET Owner (Policyholder)                                                                 POLICY INFORMATION
Your Name                                                                         Your Policy

Your                                                                              Do you have any personal insurance for you or your Pet with other company?
Address                                                                             Yes     No (if Yes, please fill in the following)

                                                                                  Type of Insurance: Pet    Household   Public Liability Travel
                                                                                    Others ______________________________________________________
(Home)                                      (Mobile)                              Name of Insurance Company: _____________________________________

E-mail                                                                           Policy No.: _____________________________________________________

Insured PET (please tick the following boxes, if appropriate)
Pet’s Name                                                                                 Microchip No.

Species:        Dog          Cat          Age                                              Colour

    Bodily Injury          Third Party Liability         Funeral Services           Holiday Cancellation           Advertising Expenses            Overseas Cover

Date of Incident                                                                     Location of Incident

Whom take care of the Pet at the                                                     Relationship with
material time of Incident                                                            Policyholder

Circumstances & Cause
of Incident

Name of Third Party / Victim                                                         Contact No/ Address

Nature/Extent of Loss/Injury                                                         Loss Estimate (HK$)

Whose Negligence                                                                     Reason

Police Station (reference number)

Eye-witness                                 Yes      No
(If yes, please advise full name, address & contact number, if any)

Advertising                                              Date of Departure                                      Holiday      From                      To
Expenses            HK$                                  (Overseas only)                                        Duration

Details of Recovery            Yes: Please advise the compensation amount
                               No: Please advise of the details of liable party

                                                               AUTHORIZATION / DECLARATION
I hereby authorize any person, party and/or authority to furnish to Blue Cross (Asia-Pacific) Insurance Limited (“the Company”) or its authorized representative, any and
all information with respect to my loss. A Photostat copy of this authorization shall be considered as effective and valid as original.
I declare to the best of my knowledge and belief that the above statements and particulars, including any attachment herein, are true, complete and correct. Deliberate
misrepresentation of the pet’s condition or the omission of any material facts may result in the denial of the claim and/or cancellation of the policy. I authorize any
Veterinarian who has treated my pet to provide to the Company any details they may require. I fully understand and agree that if I have made or shall make any false
statement or concealment, all rights to recovery under the Policy shall be forfeited. The issuance or completion of this form does not acknowledge liability or guarantee
payment of the claim on behalf of the Company.
I understand and agree that any personal information is collected or held by the Company to enable the Company to carry on insurance business and may be
used, stored, disclosed and transferred (within or outside of Hong Kong) to such individuals/organizations associated with the Company or any selected third
party as the Company may consider necessary including any other company carrying on insurance or reinsurance related business, any intermediary, claims
investigator, medical facilities, other service provider providing services relevant to insurance business, professional advisor, government authority, industry
association/federation, credit reference agencies or in the event of default, to debt collection agencies for the purpose of processing this application and providing
subsequent services for this, claim investigation, data analysis and matching, debt collection, promotion of financial products or services by the Company and its
affiliated companies, and communicating with me or any relevant organization/person as the Company may consider necessary. I have the right to obtain the
“Privacy Policy Statement”, access to and to request correction of any personal information held by the Company. Such request could be made to the
Company’s Corporate Data Protection Officer in writing at 29/F., BEA Tower, Millennium City 5, 418 Kwun Tong Road, Kwun Tong, Kowloon, Hong Kong.

Signature of Policyholder                   :                                                                                                 :
                                                                                                   Customer Service Hotline: 3412 2666
                                                                                                            (via Distributor)

                                       PET CARE INSURANCE CLAIM FORM

Pet’s Name                                                                                      Microchip No

Pet Owner’s Name

Nature of Injury or illness or treatment or operation                                               From                 To             Cost (HK$)
(Please give separate cost for each condition)

Confinement (Brief Discharge Summary, including treatments, examination procedure                   Date of              Date of        Cost (HK$)
and / or results)                                                                                   Admission            Discharge

Cause of Death (please state reason if euthanasia)                                                  Date of Death                       Cost (HK$)

Breakdown of Treatment costs for each condition (HK$):

Consultation $                         Medication/ Drug $                       Vaccination $                         Food $

X-Ray $                                Laboratory $                             Anaesthesia $                         Surgery $

Home Visits $                          Room & Board $                           Dentistry $                           Euthanasia $

Others (please specify) $

Veterinarian’s Notes (case summary)
1. How long has this pet been a client of your clinic?          Less than 6 months            More than 6 months

2. Have any conditions, illness or symptoms occurred previously which are related to the above? Yes No
       If yes, please give dates (dd/mm/yy): ____________________________________________________________________

3. According to your record, how long were the symptoms present before the first consultation: ______________________________

4. Is the treatment likely to be ongoing? Yes            No

5. Are any of the above conditions of a congenital nature? Yes                No

6. Was the treatment/ operation rendered to the Pet regarded as an emergency life saving measures? Yes                         No

                                         DECLARATION OF THE VETERINARY PRACTICE
I/We hereby declare the information and particulars stated as above to be true, correct, accurate and to the best of my / our knowledge and belief.

Signature of Veterinarian
(with Company Chop, if any)                                                                                    Date

Name of Veterinarian