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Pet Claim Form

The PET IN-HOSPITAL CLAIM FORM outlines the process for clients to submit claims for their insured pets, requiring completion of the form and submission of relevant veterinary documentation. It emphasizes the importance of providing full veterinary history for claims within the first twelve months and notes that incomplete submissions may delay assessment. Additional required documents include a final invoice and treatment estimates.

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arch.dias
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85 views2 pages

Pet Claim Form

The PET IN-HOSPITAL CLAIM FORM outlines the process for clients to submit claims for their insured pets, requiring completion of the form and submission of relevant veterinary documentation. It emphasizes the importance of providing full veterinary history for claims within the first twelve months and notes that incomplete submissions may delay assessment. Additional required documents include a final invoice and treatment estimates.

Uploaded by

arch.dias
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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PET IN-HOSPITAL CLAIM FORM

Dear Valued Client

In order for us to review your claim you need to please complete the claim form and send it back
to [email protected]. If claims are within the first twelve months from inception of the
applicable insured pet’s cover, please attach full veterinary history, provided by the vet. Once we
have received all relevant documentation (please see last page of claim form) we will be able to assess
the incident being claimed. Note that failure to provide the requested records will delay the assessment
of your claim.
Completion of this form by the Insured or his/her mandated representative, does not in any way limit
liability.
Any cost incurred in completion of this form will be the responsibility of the Insured.

A. TO BE COMPLETED BY PET OWNER

Name of Owner Name of Pet


Policy Number Breed
Phone Number Date of Birth
E-Mail

IDENTIFICATION OF PET (Please tick identification and provide a description or number)

Microchip Tattoo Birthmark Other


Description

DESCRIPTION OF ILLNESS OR INJURY AND HOW THE INJURY OCCURRED

Date symptoms were noticed / Injury occurred:

B. TO BE COMPLETED BY TREATING VET

Name of Practice
Treating Vet
Contact Person Contact Number
E-Mail History Provided YES NO

(010) 001 0141 www.oneplan.co.za


2nd Floor, South Tower, Nelson Mandela Square, Corner Maude & 5th Street, Sandton City,
Johannesburg, 2196
Underwritten By
Oneplan™ is administered by Oneplan Underwriting Managers (Pty) Ltd, an authorised financial services provider FSP43628.
Oneplan is not a benefit option regulated by the Medical Schemes Act, but a short-term insurance product underwritten by Bryte 1
Insurance Company Limited a licensed insurer and an authorised FSP (17703).
Diagnosis
Were the pet’s vaccinations up to date at the time of consultation? YES NO

COMMENTS

I, the undersigned confirm treatment of the Insured Pet as identified and described by the pet owner
in Section A of this form.

VETERINARIAN STAMP

Signature: Date:

Please make sure to also include the following Documentation or information with your form:

• Fully completed form


• Full Veterinary/Medical history
• Final Invoice for treatment/corrective procedure (with POP if applicable)
• Detailed estimate for treatment/corrective procedure (for Pre-Authorisation)

(010) 001 0141 www.oneplan.co.za


2nd Floor, South Tower, Nelson Mandela Square, Corner Maude & 5th Street, Sandton City,
Johannesburg, 2196
Underwritten By
Oneplan™ is administered by Oneplan Underwriting Managers (Pty) Ltd, an authorised financial services provider FSP43628.
Oneplan is not a benefit option regulated by the Medical Schemes Act, but a short-term insurance product underwritten by Bryte 2
Insurance Company Limited a licensed insurer and an authorised FSP (17703).

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