FAX ONLY THE FRONT PAGE OF THIS CLAIM FORM
DO NOT PAPERCLIP OR STAPLE ANYTHING THAT MAY COVER PART OF YOUR CLAIM FORM OR INVOICE
Have you included everything we need to process your claim?
Ask your veterinarian’s oce for copies of your pet’s treatment records and submit them with your claim. Treatment records
and lab results help us process your claim faster, especially if your pet was treated for more than one condition, stayed over-
night at the hospital or did not have a definite diagnosis.
Want to track the status of your claim?
Log on to the Nationwide Pet Account Access page at my.petinsurance.com and click “View Claims History.” The status of
faxed or mailed claims will be available 72 hours after they are received.
Need more claim forms?
Log on to your account at my.petinsurance.com and click on the “Pre-Filled Claim Form” link. Have claim forms handy when
you need them. Keep extra copies:
At home, with other pet-related documents
In your glove compartment
On file at your veterinarian’s oce
Have any questions?
Contact a Customer Care Representative toll free at 800-540-2016, Monday through Friday, 5:00 a.m. to 7:00 p.m. or
Saturday, 7:00 a.m. to 3:30 p.m. (Pacific).
Attention New York Residents: Any person who knowingly and with intent to defraud any insurance
company or other person files an application for insurance or statement of claim containing any materially
false information, or conceals for the purpose of misleading, information concerning any fact material thereto,
commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed
$5,000 and the stated value of the claim for each such violation.
Underwritten by Veterinary Pet Insurance Company (CA), Columbus, OH, an A.M. Best A+ rated company (2018); National Casualty Company (all other states), Columbus, OH,
an A.M. Best A+ rated company (2018). Agency of Record: DVM Insurance Agency. Nationwide, the Nationwide N and Eagle, and Nationwide is on your side are service marks of
Nationwide Mutual Insurance Company. ©2019 Nationwide. 19RET5792_NY
