Claim Form for veterinary fees
Dog and Cat
Please note there are items that are not claimable under your Policy, including, but not limited to: routine and preventative healthcare (shampoo, nail clipping,
teeth cleaning, worming, desexing and vaccinations), any illness that occurred within your waiting period and/or were a pre-existing condition. If in doubt,
please refer to your PDS and Certicate of Insurance. Please also check the excess amount on your Certicate of Insurance before completing this form.
the pet insurance people
Claim Received On: (Petplan use only)
How to make a claim:
Step 1 Please complete and sign Section 1 of this claim form
Step 2 Take the claim form to your Vet and ask them to complete Section 2 and sign
Step 3 Attach the original invoices and receipts to the completed claim form and post or email to:
Petplan Australasia Pty Ltd 1-3 Smolic Crt, Tullamarine, VIC 3043
Section 1. Policyholder to complete
Are you completing this form for a:
New illness or injury or;
Continuation illness or injury
Policy number ________________________________ Your Name ______________________________________________________________
Day phone __________________________ Home phone _____________________________ Mobile phone ______________________________
Email ________________________________________________________________________________________________________________
Postal address ____________________________________________________________ State _______________ Postcode _______________
Address where Pet resides (if different to above) ______________________________________________________________________________
Address where loss occurred (if different to above) ____________________________________________________________________________
Pet’s name _____________________________________________________________________ Pet’s date of birth _______________________
Is this pet insured with any other company?
Yes
No If Yes, what is the name of the insurance company __________________________
Have you, or are you intending to lodge a claim for this illness/injury with them?
Yes
No
Details of your pet’s illness
What condition are you claiming for? _______________________________________________________________________________________
When did you notice the rst clinical signs of the condition you are claiming? Date ____________________________ Time _____________ AM/PM
Please tell us the names and addresses of all the vet practices where the pet has attended.*Please use a separate sheet of paper for more than one.
Practice Name ____________________________________________________Phone _______________________________________________
Treatment date: From __________________ To _______________________
Payee details
ONLY NOMINATE ONE PAYEE Both the treating veterinarian/clinic and Petplan must mutually agree and are happy to proceed with this payment arrangement. Your treating veterinarian/
clinic must complete and sign the Direct Payment Section below to begin this process. As per our PDS “If We receive a request to pay the claim settlement direct to aVeterinary practice, We reserve
the right to decline this request.”
Payee account details - If Payee details are blank, a cheque will be sent to the nominated Payee
Account Account
name __________________________________ BSB ___________________ number _________________________________________
Pay Vet. I/We have arranged with my/our vet and would like this claim paid directly to them, less my excess and any other non-claimable
items. Name of the vet practice ________________________________________________________________
Pay Policyholder(s). I/We wish the claim to be paid to the policyholder(s) name on the Certicate of Insurance.
Declaration By Policyholder
I conrm that I am the policyholder and I have checked the information on this claim form and that it is all correct to the best of my knowledge and belief.
I also acknowledge and understand Petplan’s Privacy Policy*
Signature _________________________________ Date __________________________
*Privacy Policy: please refer to www.petplan.com.au/privacy and legal
We value your feedback
Email us at [email protected] (remember to include a few pictures)
Section 2. Please ask your vet to complete this section
What happens next:
Once we receive the necessary documentation, your claim will
be processed as quickly and easily as possible. If you have
any questions about your claim please call us on 1300 738 225
between 8:30am – 5:00pm (AEST) Monday to Friday.
General information
Date when this pet rst registered at your practice __________________________________________________________________________
If this pet has been referred please give the name, address and telephone number of the practice which referred it.
Name __________________________________________ Phone _______________________________________________________________
Postal address ____________________________________________________________ State _______________ Postcode _______________
About the illness or injury
Is this claim a continuation of a previous claim?
Yes
No
Condition being claimed for
Date treatment
began
Date treatment
ended
Invoice Amount
According to your notes, when did the pet owner rst notice clinical signs of the condition?
Date __________________________________________________________ Time ____________________________________________ AM/PM
Did death or euthanasia result from this illness or injury?
Yes
No Date of death ___________________________________________
If the pet was put to sleep, did you recommend this?
Yes
No
To your knowledge, has this pet been seen before for:
This illness or injury
Yes
No Any similar or related illness or injury
Yes
No Any similar or related clinical signs
Yes
No
If Yes, please provide the history with dates __________________________________________________________ Date ___________________
Total amount being claimed (inc. GST) $ ___________________
Does the total amount being claimed above match the invoice total?
Yes
No
Declaration By Veterinary Practice
This practice has an Agreement to be paid direct by Petplan
Yes
No
I have checked the information on this claim form and conrm that it is all correct to the best of my knowledge and belief.
Name _______________________________________ Position in practice ________________________________
Phone _______________________________________
Email ______________________________________________________________
Signature (Vet practice stamp here)
(To be signed by consulting Vet)
Date
PPAU-CLAIM-0318-F
