CLAIM FORM

Co-op Insurance Services is a trading name of Co-op Insurance Services Limited; registered in England and Wales with registration number 4390.

Registered office: 1 Angel Square, Manchester, M60 0AG. Co-op Insurance Services Limited is authorised and regulated by the Financial Conduct

Authority under register number 779364.

This Co-op Insurance policy is administered by Insurance Factory Limited. Insurance Factory Limited is authorised and regulated by the Financial Conduct

Authority under Financial Services Register number 306164, a company registered in England and Wales (company number 02982445); registered office:

45 Westerham Road, Bessels Green, Sevenoaks, TN13 2QB. Insurance Factory Limited is part of the Markerstudy Group of companies. Co-op Insurance

and the Co-op logo are registered trademarks of Co-operative Group Limited or its affiliates and are used under licence by Insurance Factory Limited.

Policies are underwritten by West Bay Insurance Plc. Registered office: Suite 846-848, Europort, Gibraltar. Authorised by the Prudential Regulation

Authority and regulated by Prudential Regulation Authority and the Financial Conduct Authority under register number 211787.

CLAIM FORM

PLEASE EMAIL YOUR COMPLETED FORM TO US ON CLA[email protected] OR POST TO THE CONNECT CENTRE,

KINGSTON CRESCENT, PORTSMOUTH, PO2 8QL

Section 1 - This section to be completed by the insured

Policy Number:

Title:

Claim ID:

Surname:

Cover in force:

Forename:

Inception Date:

Full Address:

Policy Dates:

Pet Name

Breed:

Postcode:

Pet Type:

Sex of Pet:

Age of Pet:

Telephone:

Purchase Price:

Email Address:

Microchip:

First date of illness,

injury or condition:

Please provide a brief description of illness/injury/condition:

Is your pet currently covered by any other insurance policy? If yes please specify below.

Name of Insurer:

Policy Number:

Expiry Date:

Has your pet been registered with any other vet? If yes, please provide contact details:

Payment instructions:

Should we make the payment direct to the Veterinary Clinic?

YES/NO

Where instructions are unclear, payment will be made to you.

Delete as appropriate

Payment to you will be made by BACS (Bankers Automated Clearing Services) if you pay for your policy by Direct Debit and the bank

account is in your own name or you are a joint account holder.

If you do not pay for your policy by monthly Direct Debit and you

would like your claim payment to be settled straight into your bank

account by BACS (Bankers Automated Clearing Services) please

provide the details here.

Account holder name:

Sort code:

Account number:

If we pay your claim by BACS a confirmation email will be sent once processed. If we do not hold your email address it will be sent by

post.

Declaration:

I declare that all details provided herein represent a true and accurate statement of the details pertaining to my claim and that I have not

omitted any details pertinent to the circumstances of the claim. I can also confirm that this claim form has been signed and dated after the

treatment has taken place.

I declare that where a claim involves a potential refund from other insurers or a third party, I hereby authorise them to remit any refund to my

insurer.

I understand and agree that information relevant to my claim(s) may be obtained from, and shared with my Vet in order for my claim(s) to be

administered.

I understand that in the event that this claim is found to be fraudulent in whole or in part, this will invalidate the policy and may render me

liable to prosecution.

Signed:

Name:

Date:

*Must be after treatment date

Co-op Insurance Services is a trading name of Co-op Insurance Services Limited; registered in England and Wales with registration number 4390.

Registered office: 1 Angel Square, Manchester, M60 0AG. Co-op Insurance Services Limited is authorised and regulated by the Financial Conduct

Authority under register number 779364.

This Co-op Insurance policy is administered by Insurance Factory Limited. Insurance Factory Limited is authorised and regulated by the Financial Conduct

Authority under Financial Services Register number 306164, a company registered in England and Wales (company number 02982445); registered office:

45 Westerham Road, Bessels Green, Sevenoaks, TN13 2QB. Insurance Factory Limited is part of the Markerstudy Group of companies. Co-op Insurance

and the Co-op logo are registered trademarks of Co-operative Group Limited or its affiliates and are used under licence by Insurance Factory Limited.

Policies are underwritten by West Bay Insurance Plc. Registered office: Suite 846-848, Europort, Gibraltar. Authorised by the Prudential Regulation

Authority and regulated by Prudential Regulation Authority and the Financial Conduct Authority under register number 211787.

Section 2 - This section to be completed by the Veterinary Surgeon

Age of pet: How long have you

been treating the

animal?

If this is a referral, please advise of the practice name and address that referred the case:

Date Diagnosis Treatment Cost (inc VAT)

Has the animal received treatment for any of the above, or any related conditions before?

YES/NO

If yes, please provide details: Delete as appropriate

Is this a continuation claim?

YES/NO

Delete as appropriate

Do you consider this to be a hereditary/congenital condition?

YES/NO

Delete as appropriate

If a home visit or out of hours treatment took place, was it essential and would the pet's

condition have worsened without this happening?

YES/NO

Delete as appropriate

Has the pet died as a result of the illness/injury mentioned above?

YES/NO

Delete as appropriate

If the claim payment is a direct settlement to be paid straight Account name:

into the Surgery bank account by BACS (Bankers Automated

Clearing Services) please provide the details here.

Sort code:

Account number:

A FULL CLINICAL HISTORY AND AN ITEMISED RECEIPT OR ACCOUNT MUST BE ENCLOSED FOR

VETERINARY FEE CLAIMS

Declaration by Veterinary Surgeon: Veterinary Practice Stamp and VAT No:

I certify that, to the best of my knowledge all the information

contained on this form is correct and that, in my opinion, the

condition treated would not have been present upon the date of the

inception of the policy. I also confirm that, in my opinion, the fees

charged are my normal practice fees relating to this matter.

Signed:

Name:

Date: