Fillable Pet Insurance Claim Form tesco.petclaims@uk.rsagroup.com

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Pet Insurance Claim Form tesco.petclaims@uk.rsagroup.com

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The Pet Insurance Claim Form tesco.petclaims@uk.rsagroup.com form is 2 pages long and contains:

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C. About your pet’s condition
Condition 1 Condition 2
Please tell us when you noticed your pet was unwell or injured.
Time and date Time and date
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 Yes
No
Date
Yes
No
Date
your pet’s condition before seeing your vet? Please call
0800 1974949 if required in the future.
Was your pet under your care at the time of the illness/injury/incident? Yes
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
No
D. Your previous veterinary practices (Please tell us the vet(s) details where your pet was previously registered)
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 Tesco Bank 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 Tesco Bank
Pet Insurance in connection with managing and handling claims. 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.
Please note: If we decide we cannot pay some or all of your claim, it is your responsibility to pay your vet.
IF ANY REQUIRED INFORMATION IS NOT RECEIVED THEN THERE WILL BE A DELAY TO YOUR CLAIM.
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:
Dated
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.
b. WHO WOULD YOU LIKE US TO PAY: Policyholder:
Joint policyholder: Vet/Organisation:
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: Tesco Pet Insurance, Freepost - RSJG-ZJTB-GAGH, PO Box 1363, Peterborough, PE2 2QZ.
Our Claims Helpline is 0345 078 3860.
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 the
vets that your pet has been registered with is
submitted with the claim form.
If this claim is for continuation condition then
please ensure that the medical history since the
last claimed date of treatment 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
can batch your invoices up but you must submit
your claims every 3-6 months.
Your policy does not cover:
• Any condition, illness or physical abnormality
that exists before the policy started
• Any accident that happened within the first 5 days
after the policy start date (ACCIDENT & INJURY
COVER ONLY)
• Any condition that started within the first
14 days after the policy start date
Claim Form tesco.petclaims@uk.rsagroup.com
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.
Policy number (must be completed)
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
Pet Insurance
B. About your pet
Pets Name*
How long have you owned the pet?
Cat Dog
Male Female
Breed
Date of birth
Your pet’s microchip number:
* 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.
DD/MM/YYYY
DD/MM/YYYY
DD/MM/YYYY
HH:MM DD/MM/YYYY
HH:MM DD/MM/YYYY
DD/MM/YYYY
DD/MM/YYYY
DD/MM/YYYY
DD/MM/YYYY
DD/MM/YYYY
✔
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 the Practice:
Practice Address: Postcode:
Email Address: Phone Number:
Date:
F. The vet must fill in this section about each condition
Please advise when the pet was registered at your practice Date
If this pet was referred to you, please advise the name and address of the registered
vet which referred it, and submit the referral letter/report with this claim.
Postcode
Please advise if you are a member of the RSA preferred
referral network Yes
No
If any part of this claim is for dental treatments 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
Treatment recommended Yes
No
Treatment was carried out Yes
No
If a house call was made, you must confirm below 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.
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.
IF ANY REQUIRED INFORMATION IS NOT RECEIVED THEN THERE WILL BE A DELAY IN PROCESSING THE CLAIM.
Tesco Bank Pet Insurance is arranged, administered and underwritten by Royal & Sun Alliance Insurance plc. Registered in England and Wales (No. 93792) 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. Tesco Personal Finance plc.
Registered in Scotland, registration no. SC173199. Registered office: 2 South Gyle Crescent, Edinburgh EH12 9FQ. Authorised by the Prudential Regulation Authority and regulated by the Financial
Conduct Authority and the Prudential Regulation Authority. 453340M (04-20)
Condition 1 Condition 2
What is the diagnosis of the condition (if no diagnosis
has been made please provide the main 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 of treatment. From
To From
To
Did the condition being claimed for result in the
Yes
No
Yes
No
death or euthanasia of the pet?
Date of death
Date of death
Please tell us the date that the clinical signs
Date
Date
were first noticed (as noted on your clinical records).
Has this pet had this condition or clinical signs before,
Yes
No
Yes
No
or any related condition or clinical signs before?
(If ‘Yes’ we will need the medical history to show the dates and full details.)
The body condition score for the pet.
Scale 1-5 please add the score in the box
Scale 1-9 please add the score in the box
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?
G. The attending vet or a person authorised by the vet must fill in this section
Please advise the cost of treatment incl. VAT Condition 1 £
Condition 2 £
If the condition being claimed for is new please enclose a full medical history for the pet.
If the condition is ongoing please enclose the medical history since the last claim.
Please note there can always be a risk in sending personal information via email.
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
DD/MM/YYYY
DD/MM/YYYY
DD/MM/YYYY
DD/MM/YYYY
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Pet Insurance Claim Form tesco.petclaims@uk.rsagroup.com

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Completed 31 October 2020

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