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Get Trupanion Claim Form 2011-2024

Signature of attending veterinarian Print name Part C Claim submission By toll free fax By mail Claims ExpressTM Trupanion 907 NW Ballard Way Seattle WA 98107 A great way to better serve pet owners - have us pay you directly rev - 8. Claim Total I understand I am financially responsible to my veterinarian for the entire treatment. I understand that this claim may not be covered or may exceed my plan benefits. I authorize my veterinarian s to release my pet s medical records to Trupanion. Claims must be submitted for processing within 90 days of treatment or service. Claim Form Fax 1. 866. 405. 4536 Phone 1. 800. 569. 7913 Part A To be completed by pet owner IMPORTANT We want to respond to your claim as quickly as possible so please fill out ALL information below as well as attaching 1. Your pet s medical records from all previous and current veterinary or emergency clinics 2 years prior to enrollment through present. Unless you have provided the history previously then just any new medical history. 2. A copy of your veterinarian s itemized invoice or an official pharmacy receipt. Name Pet s name Address Species Policy Cat Dog Male Pet s Age Female Sex Telephone Spayed/Neutered Preferred Contact Times Yes No Has your pet been to any other vets prior to enrollment Email Please list all veterinary hospitals visited 2 years prior to enrollment through present. Claim Total I understand I am financially responsible to my veterinarian for the entire treatment. I understand that this claim may not be covered or may exceed my plan benefits. I authorize my veterinarian s to release my pet s medical records to Trupanion* Claims must be submitted for processing within 90 days of treatment or service. Date mm/dd/yy Your signature FOR VETERINARIAN USE ONLY This pet required care due to an Illness Process as Claims ExpressTM direct payment to the veterinarian Accident/Trauma Type and cause of injury OR illness diagnosis Date of injury OR when illness first appeared mm/dd/yy Has this pet been seen by another vet clinic If yes which clinic Practice Stamp or Printed Name Number of Clinic Has the pet owner been following your recommended routine care program I confirm to the best of my knowledge the above statements are true in every aspect. 11 Trupanion plans are underwritten by American Pet Insurance Company. Call and ask about a pre-approval 1. Claim Form Fax 1. 866. 405. 4536 Phone 1. 800. 569. 7913 Part A To be completed by pet owner IMPORTANT We want to respond to your claim as quickly as possible so please fill out ALL information below as well as attaching 1. Your pet s medical records from all previous and current veterinary or emergency clinics 2 years prior to enrollment through present. Your pet s medical records from all previous and current veterinary or emergency clinics 2 years prior to enrollment through present. Unless you have provided the history previously then just any new medical history. 2. A copy of your veterinarian s itemized invoice or an official pharmacy receipt. .

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