Pet Insurance
Claim Form tesco.petclaims@uk.rsagroup.com
Once you and your vet have completed the form, the quickest way to get it to us is simply email it to the address above with the supporting
documents. Alternatively you can send it by post to: Tesco Pet Insurance, Lynchwood Park, Peterborough, PE2 6GG.
Our Claims Helpline is 0345 078 3860.
A. About you (the Policyholder)
If your name or address has changed, please tick
(Please note that changes to your address may affect your premium)
Your name, address and postcode
B. About your pet
Pets Name*
IMPORTANT INFORMATION – PLEASE READ
Is this claim for a:
New Condition
Please complete all sections
Continuation Condition
Please complete sections A, B & E
Daytime tel
Mobile tel
Email
Please ensure you provide us with your mobile number and email
address so that we can keep you informed of the progress of your claim.
Policy number (must be completed)
Cat Dog
Male Female
Breed
How long have you owned the pet?
Date of birth
Your pet’s microchip number:
* If you have more than one pet insured with us, please
ensure you enter the correct pet’s name and only one
claim form per pet.
If this claim is for a new condition please ensure
that the pet’s full medical history from all the
vets that your pet has been registered with is
submitted with the claim form.
If this claim is for continuation condition then
please ensure that the medical history since the
last claimed date of treatment is submitted with
the claim form.
PLEASE NOTE THAT IF ANY SECTION OF
THE CLAIM FORM IS NOT FILLED IN, OR THE
SUPPORTING INFORMATION IS NOT SUBMITTED,
THIS WILL DELAY YOUR CLAIM.
if you are claiming for continuation treatment you
can batch your invoices up but you must submit
your claims every 3-6 months.
Your policy does not cover:
• Any condition, illness or physical abnormality
that exists before the policy started
• Any accident that happened within the first 5 days
after the policy start date (ACCIDENT & INJURY
COVER ONLY)
• Any condition that started within the first
14 days after the policy start date
C. About your pet’s condition
Condition 1 Condition 2
Please tell us when you noticed your pet was unwell or injured.
If your pet has had the same or similar changes in health we
require the first date.
A description of the changes to your pet’s health that you noted.
Did you contact our 24 hour vetfone service for advice on
your pet’s condition before seeing your vet? Please call
0800 1974949 if required in the future.
Was your pet under your care at the time of the illness/injury/incident?
If no, please provide the name and address of any authorised
third party looking after your pet at the time of the incident
If your claim is for an injury, do you believe that another person was at fault? If so, please provide details separately Yes
No
Date Date
Yes
No
Date
Yes
No
Date
Yes
No
Yes
No
D. Your previous veterinary practices (Please tell us the vet(s) details where your pet was previously registered)
Practice name Practice name Please tell us your name and address at that
time, if it was different to the name and address
in Section A.
Postcode
Address Address
Postcode Postcode
Phone number Phone number
Date: from to Date: from to
E. Your Declaration, who to pay and Data Protection notice (Please complete boxes a & b below to tell us who to pay)
I declare, to the best of my knowledge and belief, that all the information provided in this form is true and complete. Tesco Bank Pet Insurance will process your
data in accordance with our privacy notice which can be found online at www.rsainsurance.co.uk/privacy-policy. I agree that information provided may be shared
with my vet and could include updates on my claim. Please ensure you provide us with your mobile number and email address so that we can keep you informed of
the progress of your claim.
a. YOUR DECLARATION. By ticking the following box, I confirm that I agree with the above statement:
My name is I am the Policyholder: I am the Joint policyholder: Dated
b. WHO WOULD YOU LIKE US TO PAY: Policyholder: Vet/Organisation:
c. PAYMENT METHOD: If we are paying your vet, we will pay them by BACS if we hold their bank details. Otherwise we will send them a cheque. If you pay your
premium by direct debit, we will pay any settlement amount into that account. If you pay your premium by any other method, settlement will be by cheque.
Please note: If we decide we cannot pay some or all of your claim, it is your responsibility to pay your vet.
IF ANY REQUIRED INFORMATION IS NOT RECEIVED THEN THERE WILL BE A DELAY TO YOUR CLAIM.
If the condition being claimed for is new please enclose a full medical history for the pet.
If the condition is ongoing please enclose the medical history since the last claim.
F. The vet must fill in this section about each condition
Please advise when the pet was registered at your practice Date If a house call was made, you must confirm below why it was absolutely
essential.
If this pet was referred to you, please advise the name and address of the registered
vet which referred it, and submit the referral letter/report with this claim.
Postcode
Please advise if you are a member of the RSA preferred
referral network Yes
No
If any part of this claim is for dental treatments please tell us the date prior
to the claimed problem being noted that the pet had its teeth checked, and if
treatment was recommended at this check up was this carried out?
Treatment recommended Yes
No
Date
Treatment was carried out Yes No
Condition 1
What is the diagnosis of the condition (if no diagnosis
has been made please provide the main clinical signs).
Please tell us the treatment dates for this claim
Is this claim for a continuation of treatment?
If yes, please advise the previous dates of treatment.
Did the condition being claimed for result in the
death or euthanasia of the pet?
Please tell us the date that the clinical signs
were first noticed (as noted on your clinical records).
From
To
Yes No
From To
Yes
No
Date of death
Date
Has this pet had this condition or clinical signs before,
Yes No
or any related condition or clinical signs before?
(If ‘Yes’ we will need the medical history to show the dates and full details.)
The body condition score for the pet.
If this claim is for a cruciate rupture, is this solely the result of a trauma
If the pet was seen out of hours please confirm why this was and whether the
treatment could have waited until normal surgery hours.
Condition 2
From To
Yes No
From To
Yes No
Date of death
Date
Yes No
Scale 1-5 please add the score in the box
Scale 1-9 please add the score in the box
or is there any breed predisposition, underlying disease or conformational issue?
G. The attending vet or a person authorised by the vet must fill in this section
Please advise the cost of treatment incl. VAT Condition 1 £ Condition 2 £
I declare to the best of my knowledge and belief that all information provided in this claim form is true and complete. The fees I have charged are no
more than the fees I would normally charge my clients.
Name: Position in the Practice:
Practice Address: Postcode:
Email Address: Phone Number:
Date:
DD/MM/YYYY
IMPORTANT: Please ensure that a dated and itemised breakdown of all treatment costs is attached to the claim form before you send it to us.
IF ANY REQUIRED INFORMATION IS NOT RECEIVED THEN THERE WILL BE A DELAY IN PROCESSING THE CLAIM.
Tesco Bank Pet Insurance is arranged, administered and underwritten by Royal & Sun Alliance Insurance Ltd. Registered in England and Wales (No. 93792) at St. Mark’s Court, Chart Way,
Horsham, West Sussex, RH12 1XL. Authorised by the Prudential Regulation Authority and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. Tesco
Personal Finance plc. Registered in Scotland, registration no. SC173199. Registered office: 2 South Gyle Crescent, Edinburgh EH12 9FQ. Authorised by the Prudential Regulation Authority
and regulated by the Financial Conduct Authority and the Prudential Regulation Authority. 453340Q (10-23)
Please note there can always be a risk in sending personal information via email.
