VPI PET INSURANCE CLAIM FORM NO COVER SHEET NECESSARY. Fax to: 714-989-5600 No.of pages: Take this form to your veterinarian to complete Section 2. Veterinarian’s signature not required. 1 2 POLICYHOLDER INFORMATION POLICY NO: PET NAME: WELLNESS TREATMENTS BREED: AGE: NAME: ADDRESS: CITY: STATE: ZIP: PHONE (H): PHONE (B): EMAIL: / / Annual Lab Tests / / Vaccinations Dental / / / / Spay/Neuter / / Heartworm/Flea Medication / / DIAGNOSIS(ES) TREATMENT DATE 5 TOTAL AMOUNT SUBMITTED $ / / / / / / / / / / / / / FAX: 714-989-5600 By signing this Claim Form, I confirm that to the best of my knowledge the information I have provided is true and correct. I authorize the release of my pet's medical records to Veterinary Pet Insurance Company/DVM Insurance Agency. POLICYHOLDER SIGNATURE and DATE X CF-1(08-09) / (Preferred Method) You must submit receipts for all veterinary service charges. All submitted fees may not be eligible for coverage. Fees that exceed benefit schedule limits are your responsibility. 4 TREATMENT DATE Wellness Exam Please provide a diagnosis, or a tentative diagnosis, not a description of services performed. 3 Fill in below. ONE CLAIM FORM PER PET. You must submit itemized receipts. You must provide us with veterinary medical records when we request them. Claims that are NOT COMPLETE or MISSING itemized, legible receipts or invoices may be delayed. / ©2009 Veterinary Pet Insurance Company / 10RET928 HOSPITAL/ CLINIC HOSPITAL/ CLINIC MAIL: OR VPI Claims Department PO Box 2344, Brea CA 92822 PLEASE DO NOT USE STAPLES, PAPER CLIPS OR TAPE to attach receipts or invoices to your claim form. Visit the VPI Policyholder Portal at my.petinsurance.com to download claim forms, view claims status and more. VPI DOCUMENT CENTER USE ONLY CLAIMS NOTES (VPI use only) FAX ONLY THE FRONT OF THIS CLAIM FORM. NO COVER SHEET REQUIRED. CLAIM FORM CHECKLIST ✓ ❑ I entered in my policy number, pet information and my contact information. ❑ This claim form includes only one pet. ❑ My veterinarian helped me complete Section 2 with the diagnosis(es), treatment date and the name of the hospital/clinic. ❑ I included all of my itemized and legible receipts/invoices. ❑ My pet's name and policy number are clearly identified on each receipt/invoice. ❑ I added up all my eligible receipts and entered the Total Amount Submitted. ❑ I signed and dated this claim form. (My veterinarian is not required to sign this form.) ❑ I submitted this claim form and all supporting receipts/invoices to the VPI Claims Department. I understand that claim forms that are incomplete or missing itemized and legible supporting receipts/invoices may be delayed. ❑ I kept a back-up copy of all documentation submitted for my records. ❑ If medical records are requested to process this claim, I understand that it is my responsibility to provide them to VPI. Two ways to submit your claim: Fax 714-989-5600 – OR – VPI Claims Department, PO Box 2344, Brea, CA 92822 If FAXING your claim, DO NOT MAIL IT IN. Duplicate claims submission may delay processing. Fraud Warning: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and may subject such person to criminal and civil penalties. Not applicable in Nebraska, Oregon and Vermont.
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