928_Claim Form Update_wingdings_1_2:Daily Mail Claim Form F

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:
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Annual Lab Tests
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Vaccinations
Dental
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Spay/Neuter
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Heartworm/Flea Medication
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DIAGNOSIS(ES)
TREATMENT
DATE
5
TOTAL AMOUNT SUBMITTED
$
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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.
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©2009 Veterinary Pet Insurance Company
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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.