C ABOUT YOUR PET’S CONDITION
D YOUR PREVIOUS VETERINARY PRACTICES
(please tell us the vet(s) details where your pet was previously registered)
Date: from to
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.
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.
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
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 firstname.lastname@example.org
µ PET INSURANCE
IMPORTANT INFORMATION - PLEASE READ
Is this claim for a:
Please complete all sections
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
Yes No Date
Please call 0800 0728190 if required in the future.
Was your pet under your care at the time of the
No Yes No
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
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:
a YOUR DECLARATION. By ticking the following box, I confirm that I agree with the above statement:
My name is
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.
Please note: if we decide we cannot pay some or all of your claim, it is your responsibility to pay your vet.