By completing this form I confirm I have checked the information given and
that it is correct to the best of my knowledge.
Claims payments will be paid into the bank account from which your premium is collected.
Please ensure you have given us your email address in Section 2 to avoid delay in settlement.
Direct Debit customers
Holiday dates
Date booked
Destination
Date of cancellation
Reason for cancellation
Documents required to support claim
Travel and accommodation expenses claimed
tofrom
4. Policyholder to complete
ABOUT YOUR HOLIDAY
Booking invoice Cancellation invoice Receipts
Amount claimed £
Amount claimed £
Amount claimed £
Condition
Date of onset
Treatment carried out
Was it emergency life-saving treatment?
Name
Practice name
Date
Date client was advised of treatment required
6. Veterinary practice to complete
DETAILS OF ILLNESS/INJURY
Petplan practice no.
To ensure this claim is dealt with quickly please note your Petplan practice number here
Total amount claimed in figures
£
5. Policyholder to complete
PAYEE DETAILS
Date of treatment
A.
B.
C.
Petplan is a trading name of Pet Plan Limited (Registered in England No. 1282939) and Allianz Insurance plc (Registered in England No. 84638), Registered office: 57 Ladymead, Guildford,
Surrey GU1 1DB. Pet Plan Limited is authorised and regulated by the Financial Conduct Authority. Allianz Insurance plc is authorised by the Prudential Regulation Authority and regulated by the
Financial Conduct Authority and the Prudential Regulation Authority.
Claim Form for Holiday Cancellation
Your claim will be delayed if you do not supply all of this information
Yes No
For Petplan use only
1. Policyholder to complete
POLICY NUMBER
Reference letters not required
3. Policyholder to complete
ABOUT YOUR PET
Is your pet a Dog Cat Rabbit
Pet’s name
Pedigree name
Breed
If crossbreed, please state dominant breed
(dogs only)
2. Policyholder to complete
ABOUT YOU
Policyholder’s address
Postcode
Please tick here if this is different to the address on your Certicate of
Insurance.
Your policy records will be updated with these details.
Policyholder’s surname
Policyholder’s first name
Contact no.
Email address
Is your holiday insured with any other company?
If Yes, please supply details of other insurer
Yes No
(Required for electronic payments)
Pet’s microchip no.
Male Female
Pet’s date of birth
Date you first owned your pet
Is your pet insured with any other company?
If Yes, please state which company
Yes No
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PLEASE COMPLETE A SEPARATE FORM FOR EACH PET
N.B. Issue of this form does not constitute admission of liability on the part of the Insurers.
Please complete the form and ensure it is saved before you send it.
Missing information will delay your claim.
We’re happy to help!
If you need any help completing this form, please visit
petplan.co.uk/my-petplan/howtoclaim.asp
Important note - Please send completed claim forms including copies of all receipts and vet histories to: [email protected].
10233/1 01.22
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Policyholder name
Date
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