Fillable PET INSURANCE CLAIM FORM petclaims@morethan.com

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PET INSURANCE CLAIM FORM petclaims@morethan.com

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C ABOUT YOUR PET’S CONDITION
D YOUR PREVIOUS VETERINARY PRACTICES
(please tell us the vet(s) details where your pet was previously registered)
Practice name
Address
Postcode
Phone number
Date: from to
Practice name
Address
Postcode
Phone number
Date: from to
Please tell us your name and address at that
time, if it was different to the name and address
in Section A.
Postcode
IF ANY INFORMATION IS NOT RECEIVED THEN THERE WILL BE A DELAY TO YOUR CLAIM.
B ABOUT YOUR PET
Your pet’s name
* If you have more than one pet insured with us, please
ensure you enter the correct pet’s name and only one
claim form per pet.
Cat Dog
Male Female
Breed
Date of birth
Your pet’s microchip number:
How long have you owned your pet?
A ABOUT YOU (the policyholder)
If your name or address has changed, please tick.
(Please note that changes to your address may affect your premium)
Your name, address and postcode
Daytime tel
Mobile tel
Email
Please ensure you provide us with your mobile number and email
address so that we can keep you informed of the progress of your claim.
Once you and your vet have completed the form, the quickest way to get it to us is simply email it to the address above with
the supporting documents. Alternatively you can send it by post to: µ, Freepost RSKZ-LZSG-KSXB, PO Box 1362,
Peterborough PE2 2QY. Our Claims Helpline is 0330 100 7801.
CLAIM FORM petclaims@morethan.com
µ PET INSURANCE
IMPORTANT INFORMATION - PLEASE READ
Is this claim for a:
New condition
Please complete all sections
Continuation condition
Please complete sections A,B&E
If this claim is for a new condition please
ensure that the pet’s full medical history from
all of the vets that your pet has been registered
with is submitted with the claim form.
If this claim is for a continuation condition
then please ensure that the medical history
applicable since the date of treatment of the
last claim is submitted with the claim form.
PLEASE NOTE THAT IF ANY SECTION OF
THE CLAIM FORM IS NOT FILLED IN, OR
THE SUPPORTING INFORMATION IS NOT
SUBMITTED, THIS WILL DELAY YOUR CLAIM
If you are claiming for continuation treatment
you must submit claims every 3-6 months.
Therefore, in order to save paper, you do not
need to submit a claim for every visit to your
vet but you can batch the invoices up.
Your policy does not cover:
• Any changes that you or your vet noticed
in your pet’s health or behaviour before the
policy started or any conditions that arise
from those changes
• Any accident that happened within the first
48 hours after the policy start date
• Any condition that started within the first 14
days after the policy start date
• For a full explanation of what your policy
does and does not cover please refer to
your Policy Booklet
Policy number (Must be completed)
Time & Date Time & Date
CONDITION 1 CONDITION 2
Please tell us when you first noticed your pet was unwell
or injured. If your pet has had the same or similar changes
in health we require the first date.
A description of the changes to your pet’s health
that you noted
Did you contact our 24 hour vetfone service for advice
on your pet’s condition before seeing your vet? Yes
No Date
Yes No Date
Please call 0800 0728190 if required in the future.
Was your pet under your care at the time of the
Yes
No Yes No
illness/injury/incident?
If no, please provide the name and address of any authorised
third party looking after your pet at the time of the incident
If your claim is for an injury, do you believe that another person was at fault? If so, please provide details separately. Yes
No
DD/MM/YYYY
DD/MM/YYYY
DD/MM/YYYY
DD/MM/YYYY
DD/MM/YYYY
DD/MM/YYYY
E YOUR DECLARATION, WHO TO PAY AND DATA PROTECTION NOTICE (please complete boxes a & b below to tell us who to pay)
I declare, to the best of my knowledge and belief, that all the information provided in this form is true and complete. I agree that µ Pet Insurance
may seek any information it requires from any vet. I accept that the information provided may be released to other companies who provide a service to
µ Pet Insurance in connection with managing and handling claims.
b WHO WOULD YOU LIKE US TO PAY: Policyholder:
Joint policyholder:
Vet Practice/Organisation:
a YOUR DECLARATION. By ticking the following box, I confirm that I agree with the above statement:
My name is
Dated
I am the Policyholder: I am the Joint policyholder:
c PAYMENT METHOD: If you pay your premium by Direct Debit we will automatically pay any settlement into that account by electronic transfer. If Direct Debit is not
used please ensure that you provide us with your contact details in Section A above, in the event we have to contact you to agree an alternative payment method.
DD/MM/YYYY
Please note: if we decide we cannot pay some or all of your claim, it is your responsibility to pay your vet.
HH:MM DD/MM/YYYY
HH:MM DD/MM/YYYY
DD/MM/YYYY
CONDITION 1
£
CONDITION 2
£
Please advise the cost of treatment incl. VAT
Please advise the date this pet was registered at your practice.
If this pet was referred to you, please advise the name and address of the
registered vet, and submit the referral letter/report with the claim.
Postcode
Please advise if you are a member of
RSA Preferred referral network Yes
No
If any part of this claim is for dental treatment please tell us the date prior to
the claimed problem being noted that the pet had its teeth checked, and if
treatment was recommended at this check up was this carried out?
Date
If a house call was made, you must confirm in writing why it was absolutely
essential.
If the pet was seen out of hours please confirm why this was and whether the
treatment could have waited until normal surgery hours.
F THE VET MUST FILL IN THIS SECTION ABOUT EACH CONDITION
I declare to the best of my knowledge and belief that all information provided in this claim form is true and complete. The fees I have charged are no more
than the fees I would normally charge my clients.
Name Position in Practice
Practice Address Postcode
Email Address Phone Number
Date
G THE ATTENDING VET OR A PERSON AUTHORISED BY THE VET MUST FILL IN THIS SECTION
Please note that the Veterinary Surgeon does not have to be an appointed representative of µ Pet Insurance in order to fill in this section of the claim
form for you because it is not a regulated activity under FCA regulations.
IMPORTANT: Please ensure that a dated and itemised breakdown of all treatment costs is attached to the claim form before you send it to us. The costs must
be clearly apportioned between each condition being claimed for. Please do not use highlighter pen to apportion costs.
IF ANY REQUIRED INFORMATION IS NOT RECEIVED THEN THERE WILL BE A DELAY TO YOUR CLAIM
CONDITION 1 CONDITION 2
What is the diagnosis of the condition
(If no diagnosis has been made
please provide the clinical signs)
Please tell us the treatment dates for this claim From
To
From
To
Is this claim for a continuation of treatment? Yes
No
Yes
No
If Yes, please advise the previous dates From
To
From
To
of treatment.
Did the condition being claimed for result in the Yes
No Date of death
death or euthanasia of the pet?
The body condition score for the pet.
Body Score
If this claim is for a cruciate rupture, is this solely the result of a trauma or is there any breed predisposition, underlying disease or conformational issue?
Please tell us the date that the clinical
signs were first noticed (as noted on your Date
Date
clinical records).
Has this pet had this condition or clinical signs
Yes
No Yes No
before, or any related condition or clinical signs
before?
(If ‘Yes’ we will need the medical history to show the dates and full details)
Scale (1-5) (tick to complete)
morethan.com/pet
µ is a trading style of Royal & Sun Alliance Insurance plc (No. 93792). Registered in England and Wales at St. Mark’s Court, Chart Way, Horsham, West Sussex RH12 1XL. Authorised by the Prudential Regulation Authority and
regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Calls may be recorded and monitored. Please note there can always be a risk in sending personal information via email.
R00862G (03-20)
If the condition being claimed for is new please complete all sections and enclose a full medical history for the pet.
If the condition is ongoing please complete the sections with grey box and enclose the medical history since the last claimed date of treatment.
Treatment recommended Yes
No
Treatment was carried out Yes
No
Scale (1-9) (tick to complete)
DD/MM/YYYY
DD/MM/YYYY
DD/MM/YYYY
DD/MM/YYYY
DD/MM/YYYY
DD/MM/YYYY
DD/MM/YYYY
DD/MM/YYYY
DD/MM/YYYY
DD/MM/YYYY
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DD/MM/YYYY
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DD/MM/YYYY
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PET INSURANCE CLAIM FORM petclaims@morethan.com

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Completed 21 November 2020

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