Fillable Form 1: CLAIM FORM VETERINARY FEE ABOUT YOU

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Form 1: CLAIM FORM VETERINARY FEE ABOUT YOU

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The Form 1: CLAIM FORM VETERINARY FEE ABOUT YOU form is 1 page long and contains:

  • 2 signatures
  • 1 check-box
  • 57 other fields

Country of origin: OTHERS
File type: PDF

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SUBMIT A CLAIM
VETERINARY FEE
CLAIM FORM
Claims cannot be processed without a completed claim form and itemized reciepts.
!
1
ABOUT YOU AND YOUR PET (ax a label if you have one)
Customer Number
Name
Address
☐ Please check
if new
address
Cell phone Home phone
Email
Pet’s name
Pet's date of birth (mm/dd/yyyy)
Sex
☐ M ☐ F
Breed
CUSTOMER PORTAL: Upload photos through My Account
or
EMAIL: claims@petlineinsurance.com
☐ Yes ☐ No
QUESTIONS?
2
ABOUT THE ILLNESS OR INJURY (to be completed by an authorized veterinary clinic employee)
Why did the animal visit the veterinary clinic today?
(include symptoms, diagnosis, illness or injury, if possible)
Is this related to a
previously noted condition?
When did you first notice
signs of the accident/illness?
☐ Yes ☐ No
☐ Yes ☐ No
☐ Yes ☐ No
☐ Yes ☐ No
☐ Yes ☐ No
☐ Yes ☐ No
☐ Yes ☐ No
☐ Yes ☐ No
Did this claim result in the death of the pet?
☐ Yes ☐ No
If yes, date of death (mm/dd/yyyy)
I have checked the information on this claim. It is true and accurate and consistent with patient
medical records held within this veterinary practice.
Name of clinic employee
Signature of clinic employee mm dd yyyy
Practice stamp or practice name
Please turn over
* There are time limitations on submitting claims. Claims must be submitted within 6 months of the date of treatment.
For cancelled policies, claims must be submitted within 60 days of cancellation.
The submission of a fraudulent claim is a criminal oense. The submission of a false or exaggerated claim may also result
in the termination of your insurance policy, and other actions as permitted by law.
3
CUSTOMER DECLARATION
By signing this claim form, I agree that the information provided is complete and accurate. I recognize that not all fees may be eligible for coverage or
may exceed my plan coverage limits. I understand this claim may be limited to fees no greater than the amount specified by the Provincial Fee Guide.
I acknowledge that I am financially responsible to my veterinarian for the entire treatment cost regardless of claim amounts paid by Petline Insurance
Company. I authorize my veterinarian or other parties to release all medical records and pertinent history for this pet and to confirm any details as
requested. I understand that the information provided about this pet will be used for claims adjudication and any related processes necessary for the
administration of my plan. (See “Important notes” for more on privacy policy).
Signature of customer mm dd yyyy
starting 3 days ago
Example: vomiting, diagnosis – gastroenteritis
☐ Dog ☐ Cat
Contact us at 1.800.581.0580 or
info@petlineinsurance.com
Type of pet Sex
Is your pet covered under another insurance plan?
■
click to sign
signature
click to edit
click to sign
signature
click to edit
SIMPLE STEPS TO MAKE A CLAIM
We will reimburse you for the costs of any services or treatment your pet has received for any accident or illness eligible for
coverage on your plan.
You are responsible for:
• The co-insurance amount applicable to your policy.
• The deductible amount applicable to your policy.
• The costs of any services or treatment your pet has received for any conditions not eligible for coverage on your plan including
conditions that started or showed symptoms before your pet’s policy started or during any applicable waiting periods.
• Any condition shown as an exclusion on your policy.
• Uninsured items (i.e. toys, treats, etc.)
Please see your Policy Wordings document for full details.
COVERAGE DETAILS
• Please retain a copy of your complete claim form and receipts for your records.
• Please use one claim form per pet.
• Issuance or completion of this form does not acknowledge liability on behalf of Petline Insurance Company.
• Claims received that are incomplete or missing information may not be processed until we have received all of the
required information.
• The deliberate misrepresentation or omission of any material facts may result in the denial of the claim and/or
cancellation of the policy.
• Your privacy is important to us. Should you have any questions as to the collection, use, or disclosure of your personal
information, please see our privacy policy at www.petlineinsurance.com/pdf/Privacy_Statement.pdf or contact us directly
at 1.800.581.0580 or info@petlineinsurance.com.
IMPORTANT NOTES
For a faster claim reimbursement, switch to direct deposit.
You can edit your Claim Payment Method in your Customer Portal or contact us.
!
Visit petlineinsurance.com for a full list of underwritten brands.
For use with policies underwritten by Petline Insurance Company. © 2021 Petline Insurance Company
1. Take your pet to any licensed veterinarian for diagnosis and treatment.
2. Pay your veterinary bill in full and have an authorized vet clinic employee complete section 2 of this claim form.
3. Fill out sections 1 and 3 of this claim form. Remember to sign your form!
4. Attach your detailed receipt(s) or original invoice to the claim form.
5. Submit your completed claim form and receipts by:
CUSTOMER PORTAL: Upload photos through My Account
EMAIL: claims@petlineinsurance.com
(When emailing attachments, please send PDF or JPG formats)
MAIL: Petline Insurance Company
301-600 Empress Street
Winnipeg, MB R3G 0R5
FAX: 1-866-501-5580
Call us at 1.800.581.0580 or email us at info@petlineinsurance.com if you have any questions.
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Form 1: CLAIM FORM VETERINARY FEE ABOUT YOU

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Completed 29 May 2021

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