µPETINSURANCE
CLAIMFORM
A ABOUT YOU(ThePolicyholder)
CLAIMS HELPLINE 0800 300 889
PLEASE NOTE that if any section of the
form is not filled in, it may delay your
claim – you MUST fill in sections A to E.
Pleasealsoreadthefollowingnotesbefore
submittinganyclaimandhaveyour
policywordingtohandforfulldetailsof
terms,conditionsandexclusions:
•Allclaimsforveterinarytreatmentfees
mustbesubmittedwithin30daysof
Firsttreatment
•Ifaclaimforanewillnessorinjury
pleaseensurethefullmedicalhistoryis
attachedtotheclaimform
•Forongoingtreatmentyoumustsubmit
ongoingclaimsevery3-6months
Your policy does NOT COVER in whole
or as part of a claim:
•Anyillnessorinjurythatstartedbefore
thepolicystartdate
•Anyillnessthatstartedwithinthefirst
14daysofthepolicystartdate
•Theexcessspecifiedinyourpolicy
schedule
•Food,fleatreatment,wormers&
vaccinations
•Dentaltreatmentunlesscausedbyinjury
Ifyournameoraddresshaschanged,pleasetick
Yourname,addressandpostcode:
ThisClaimFormshouldbecompletedandreturnedtoµ,
FREEPOST,RSKZ-LZSG-KSXBP.O.BOX15769,Birmingham,B22RA
POLICYNUMBER
Yourcontactdetails:
Daytimetel.
Eveningtel.
Mobiletel.
Email
B ABOUT YOUR PET
Yourpet’sname:
Cat
Dog
Male
Female
Breed
Dateofbirth
//
Hasyourpetbeen Yes
neutered/spayed?
No
kgs Whatistheweightofyourpet?
Note:Ifyouarenotsureaboutanyofthe
aboveinformation,pleaseaskyourvetto
completethisforyou.
C ABOUT YOUR PET’S ILLNESS OR INJURY
ILLNESSORINJURY1
ILLNESSORINJURY2
Nameofillnessorinjury
asadvisedbyyourvet.
Pleasetelluswhenyou
firstnoticedyourpet
wasinjuredorunwell.
Date&
time
Date&
time
Wasyourpetunderyourcareat
thetimeoftheillness/injury/incident?
Yes
No
Yes
No
Ifno,wasyourpetunderthecare
ofanauthorisedThirdParty?
Yes
No
Yes
No
D YOUR PREVIOUS VETERINARY PRACTICES Pleasetellusallofthevet(s)whereyourpethasbeenpreviouslyregistered
Vet’sname
Vet’sname
Address
Address
Postcode
Postcode
Phonenumber
Date:from
Pleasetellusyouraddressatthattime,if
itwasdifferenttotheaddressinsectionA.
Phonenumber
to
Date:from
to
Postcode
E YOUR SIGNATURE andWHO TO PAY
Pleasecompletejustoneofthefollowingboxes(a,b,orc)toletusknowifpaymentshouldbemadedirecttoyou,yourvetorsomeoneelse.
Ideclare,tothebestofmyknowledgeandbelief,thatalltheinformationprovidedinthisformistrueandcomplete.
Iagreethatµmayseekanyinformationitrequiresfromanyvet.
Iacceptthattheinformationprovidedmaybereleasedtoothercompanieswhoprovideaservicetousoryouinconnectionwithmanagingand
handlingclaims.
a Pleasepaymyclaimdirecttome.
b Pleasepaymyclaimdirecttomyvet.
c Pleasepaymyclaimtothepersonnamedbelow.
Yourname
Vet’sname
Name
Policyholder’ssignature
Policyholder’ssignature
Policyholder’ssignature
Date //
Date //
Date //
PLEASENOTE:ifwedecidewecannotpaysomeorallofyourclaim,itisyourresponsibilitytopayyourvet.
F YOUR VET MUST FILL IN THIS SECTION ABOUT EACH ILLNESS OR INJURY
When was this pet registered at your practice?
Date
Ifthispetwasreferredtoyou,
pleaseadvisethenameand
addressoftheregisteredvet.
//
Postcode
Doestheclaimincludeoutofhours
charges? Didanyillnessorinjurybeingclaimed
resultinthedeathoreuthanasiaof
thepet?
Yes
No
Ifyes,pleaseexplainwhytheout
ofhourstreatmentwasnecessary.
Yes
No
Ifyes,pleaseadvisetheillnessorinjury.
Ifahomevisitwasmade,wasitbecause
itwouldhaveendangeredthepet’s
healthtomoveit?
Yes
No
Ifno,pleaseadvisethereasonforthe
homevisit.
ILLNESS/INJURY1
Dateofdeath
//
ILLNESS/INJURY2
Whatarethemainclinicalsignsofeach
illnessorinjury?
Whatisthediagnosisofeachillness
orinjury?
Pleaseprovidethetreatmentdatesfor
thisclaim.
From
/
Haveyoufilledinaclaimformforthis
illnessorinjurybefore?
Yes
No
Don’tknow
Ifyes,pleasetellusthetreatmentdates
fromthepreviousclaim.
From
/
To
/
/
To
/
/
/
/
From
/
/
Yes
No
Don’tknow
From
/
To
/
To
/
/
/
/
IFTHISISANEWCLAIM,PLEASECOMPLETETHEFOLLOWINGQUESTIONSANDFORWARDTHEFULLMEDICALHISTORY
Please tell us the date or the number of
days before the first date of treatment,
that the clinical signs were first noticed.
Days
Date
/
/
Days
Date
Hasthispethadthisillnessorinjury
before,orthisillnessorinjuryanywhere
elseinoronitsbodybefore?
Yes
No
Yes
No
Hasthispethadanyrelatedillnessor
injurybefore,oranyrelatedillnessorinjury
anywhereelseinoronitsbodybefore?
Yes
No
Yes
No
Hasthispethadtheseclinicalsignsbefore,
oranyrelatedclinicalsignsanywhereelse
inoronitsbodybefore?
Yes
No
Yes
No
Hasthispethadanyrelatedclinical
signsbefore,oranyrelatedclinicalsigns
anywhereelseinoronitsbodybefore?
Yes
No
Yes
No
/
If you answer ‘yes’ to any of the previous four questions we will need the medical history to show the dates and full details.
G THE ATTENDING VET OR A PERSON AUTHORISED BY THE VET MUST FILL IN AND SIGN THIS SECTION
Pleaseadvisethecostoftreatmentincl.VAT.
ILLNESS/INJURY1
ILLNESS/INJURY2
£
£
Ideclare,tothebestofmyknowledgeandbelief,thatallinformationprovidedinthisclaimformistrue
andcomplete.ThefeesIhavechargedarenomorethanthefeesIwouldnormallychargemyclients.
PracticeStamp
Printedname:
Signature
Date
PleasenotethattheVeterinarySurgeondoesnothavetobeanappointedrepresentativeofµPetInsurance
inordertofillinthissectionoftheclaimformforyoubecauseitisnotaregulatedactivityunderFSAregulations.
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. This can be either an itemised computer printout or an itemised invoice which must state fees for consultations,
prescription charges, hospitalisation, X-rays, tests/pathologies, general anaesthetic, surgery, medication and any other fees
charged. The Veterinary Surgeon must apportion costs clearly for each illness or injury on the itemised breakdown.
www.morethan.com/pet
PART OF THE RSA GROUP
µisatradingstyleofRoyal&SunAllianceInsuranceplc(No.93792).RegisteredinEnglandandWalesatSt.Mark’sCourt,ChartWay,Horsham,WestSussex
RH121XL.AuthorisedandregulatedbytheFinancialServicesAuthority.Callsmayberecordedandmonitored.
R00724B_WEB(07-11)
/