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
A diagnosis is the medical condition treated. Please do not list symptoms (for example limping, lameness or infections are
symptoms of injuries or illnesses). Your veterinarian can help you with the diagnosis. Include a copy of your pet’s treatment
records and lab results for this visit if there is more than one diagnosis being treated, your pet stayed at the hospital overnight,
or the diagnosis has not been determined. Please do not write “See Attached” or list services shown on your invoice.
ONLINE:
FAX:
MAIL:
www.petinsurance.com/submit-claim
(714) 989-5600 No cover sheet neccessary.
Nationwide Claims Department
PO Box 2344
Brea, CA 92822-2344
click to sign
signature
click to edit
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 oce 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 oce
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 Texas Residents: Any person who knowingly presents a false or fraudulent claim for the payment
of a loss is guilty of a crime and may be subject to fines and confinement in state prison.
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_TX
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