Pet Claim Form - Vet’s Fees(Use this form for up to 2 separate injuries or illnesses per pet. If you want to claim for more thantwo illness/injuries and/or more than one pet please use an additional form.)

Policy No:

Date Downloaded:

1 Your Details

Your Name

Address

Daytime Tel. No.

Evening Tel. No.

Postcode

2 Pet’s Details

Name of pet

Type of pet

Age of pet

Dog Cat

Injury, illness or diseaseyou are claiming for andthe date when you firstnoticed the clinicalsigns.

Time

Claim A

Date

TimeDate

Claim B

If your pet has been involved in a road accident please use a separate sheet to tell us exactly how it happened.

Address

Practice where your pethas been previouslyregistered, if applicable.

Name

I hereby declare that the details given by me, are to the best of my knowledge, true and complete.I authorise the vet to provide, upon request, all copies of medical records of pets treated on my behalf.

Policyholder’s Signature Date

Email

(This section to be completed by the policyholder)

(This section to be completed by the policyholder)

CLAIM FORMS RECEIVED WHICH ARE INCOMPLETE WILL BE RETURNED TO THE POLICYHOLDER.

Declaration (This section to be completed by the policyholder)

Postcode

Address

Attending vet Practice Name

Postcode

Breed of pet

Date of purchase Price paid £

Sex of pet Male Female

Mobile No.

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Has your pet suffered with, or have youclaimed for this condition previously?

Claim A

Claim B

Yes

Yes No

No

Has your pet been routinely wormed?

Has your pet been routinely vaccinated?

Has your pet been neutered?

Yes

Yes

No

No

Yes

Me

No

VetIn the event of settlement becoming due, toWhom should payment be made?

Name

Yes NoCould this claim potentially be covered underany other policy of insurance? If Yes, pleaseprovide full details.

All schemes are underwritten by the Equine & Livestock Insurance Co Ltd (E&L®) which is authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and thePrudential Regulation Authority no. 202748. This can be checked by visiting the FCA’s website or by contacting the FCA on 0800 111 6768.

Other

Thorpe Underwood HallOuseburn

YorkYO26 9SS

Tel: 08449 809 400Fax: 08449 809 410

email claims@eandl.co.ukweb: www.eandl.co.uk

LIABILITY

The issue of this form doesnot constitute an admissionof claim liability by E&L

REQUIREMENTS

Please ensure that allsections are completed byyou as indicated.The form must be returned tous at the address shownbelow within 90 days. Faxedcopies of the claimdocumentation can be sent inadvance.Please provide us with thefollowing to accompany yourclaim:Kennel Club Documents andPedigree Certificate

SETTLEMENT

In the event of claimssettlement becoming due Wewill issue settlement byBACS transfer. Where bankaccount details have notbeen provided or this is notpossible, settlement will bedespatched by cheque.Settlement will be issued toYou unless otherwiserequested. You can select analternative payee by tickingthe relevant box on the claimform You fill in and byproviding the third partyname.

RESERVATION OF RIGHTS

E&L reserve the right toappoint loss adjusters orveterinary consultants toreview the claim and also torequest further informationfrom current or previous vetsor previous insurers.

EXCESS

Please check your policydocuments for the excessapplicable to your claim.

IMPORTANT NOTES

Contacting Us

08449 809 400

®

®

Veterinary Fees Claim Form

Name of pet Age of pet

How long has your practice known this animal?

Please can you provide a copy of the pet’s full previous medical/clinical history for the duration of ownership. Ifthere is no history available or if you cannot provide the full history please state the reason why (e.g. we are thereferral practice/first time this pet has been seen by this practice).

Diagnosis or giveclinicalsigns/symptoms ifyou have not made adiagnosis.

Dates and Costs oftreatment.

From

Cost

From

Cost

To To

In your opinion howlong had the animalhad this complaintprior to your firstconsultation?

If the animal was presented at an out of hourssurgery, or subject to a home visit, was thecondition life endangering?

Yes No Yes No

Yes No Yes NoHave you or do youintend to refer thisanimal to anothervet?

Yes No Yes No

Has the pet been seen before, for this illnessor injury?

Yes No Yes NoIf YES, is it likely the condition suffered willrequire treatment/medication for the rest ofthis pet’s life?

Yes No Yes NoIf NO, once treatment/medication has endedis this pet at a higher risk of the conditionreoccurring than a pet which has neversuffered it before?

Yes No Yes NoIs it likely the condition suffered will requirefurther treatment/medication?

In the event of death please advise us of: Cause of death

Date

If the animal was put to sleep, pleaseindicate why:

The RCVS regard an insurance claim form once signed by a vet as being a veterinary certificate with attendantserious implications. I hereby certify that I have checked the information in Section 3 above and that to the best of myknowledge it is correct. The fees I have charged are no higher than my normal practice fees.

Vet’s Signature Date

If yes, please state the name and address below andinclude a referral report:

(As noted by you, stated by the client or on the pet’s record).

If yes, please state the name and address below andinclude a referral report:

(As noted by you, stated by the client or on the pet’s record).

Illness or Injury - Claim A Illness or Injury - Claim B

3 Details of Condition and Treatments given. (This section to be completed by your vet)

Declaration (This section to be completed by your vet)

Practice Address

Practice Name

Vet Name MRCVS/FRCVSThorpe Underwood Hall

OuseburnYork

YO26 9SSTel: 08449 809 400Fax: 08449 809 410

email claims@eandl.co.ukweb: www.eandl.co.uk

To be Completed by YOUR Vet.PLEASE NOTE THAT IF ANY QUESTIONS ARE LEFT UNANSWERED IT IS LIKELY TO CAUSE A DELAY IN THEASSESSMENT OF THE CLAIM.

PLEASE NOTE THAT IF ANY QUESTIONS ARE LEFT UNANSWERED IT IS LIKELY TO CAUSE A DELAY IN THE ASSESSMENT OF THE CLAIM.

Policyholder Name:

Policy No:

Address:

Yes No Yes No

Has the pet been seen before, for any similar,related illness or injury or clinical signs?In your opinion:

Please ensure all relevant invoices are attached.

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