Cover My is a trading name of Reach Financial Services Limited. Reach Financial Services Limited is authorised and regulated by the Financial
Conduct Authority. FCA Register Number 302801.Reach Financial Services Limited is a limited company registered in England Company No:
4328466 Registered office: Kempton House, Kempton Way, PO Box 9562, Grantham, Lincolnshire, NG31 0EA.
CLAIM FORM
PLEASE EMAIL YOUR COMPLETED FORM TO [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:
Surname:
Forename:
Home
address:
Postcode:
Telephone:
Email address:
Cover in force:
Inception date:
Policy dates:
Pet name:
Breed:
Pet type:
Age of pet:
Date pet acquired:
First date of illness /
injury or condition:
Microchip number
(if applicable):
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?
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 BACS
(Bankers Automated Clearing Services) please provide the details
here.
Account holder name
Sort code
Account number
A confirmation email will be sent once processed. If we do not hold your email address it will be sent by post.
Declaration:
1. 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.
2. 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.
3. 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.
4. 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
YES/NO
-
Sex of pet:
Purchase price:
Cover My is a trading name of Reach Financial Services Limited. Reach Financial Services Limited is authorised and regulated by the Financial
Conduct Authority. FCA Register Number 302801.Reach Financial Services Limited is a limited company registered in England Company No:
4328466 Registered office: Kempton House, Kempton Way, PO Box 9562, Grantham, Lincolnshire, NG31 0EA.
Declaration by Veterinary Surgeon:
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.
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?
If yes, please provide details:
Do you consider this to be a hereditary/congenital condition?
If a home visit was made, was it because moving the pet would have endangered the pet's
health?
Has the pet died as a result of the illness/injury mentioned above?
Delete as appropriate
Delete as appropriate
Delete as appropriate
Delete as appropriate
Delete as appropriate
If the claim payment is to be paid straight into the Surgery
bank account by BACS (Bankers Automated Clearing
Services) please provide the details here.
Practice account name
Sort code
Account number
Veterinary Practice Stamp and VAT No:
A FULL CLINICAL HISTORY AND AN ITEMISED RECEIPT OR ACCOUNT MUST BE ENCLOSED FOR
VETERINARY FEE CLAIMS
YES/NO
YES/NO
YES/NO
YES/NO
Signed
Date
Print name
Is this a continuation claim?
YES/NO
Cover My is a trading name of Reach Financial Services Limited. Reach Financial Services Limited is authorised and regulated by the Financial
Conduct Authority. FCA Register Number 302801.Reach Financial Services Limited is a limited company registered in England Company No:
4328466 Registered office: Kempton House, Kempton Way, PO Box 9562, Grantham, Lincolnshire, NG31 0EA.
HOW TO CLAIM - DOCUMENTS REQUIRED HELP SHEET
To enable us to assess your claim we will require the following:
What are you claiming for?
Documents we require
Enclosed
(Tick to confirm)
Veterinary Fees
Claim form fully completed, signed (after each invoice received) and dated by you
(the named policyholder) & your Veterinary Surgeon.
A full clinical history from your Veterinary Surgeon.
An itemised invoice/receipt showing all the treatment carried out.
Death Benefit
Claim form fully completed and signed by you (the named policyholder) & your
Veterinary Surgeon.
Purchase receipt from the breeder or donation receipt if adopted through a rescue
organisation.
Witness statement of the incident that caused the death (if applicable)
Theft or Straying
Claim form fully completed and signed by you (the named policyholder) & your
Veterinary Surgeon.
Purchase receipt from the breeder or donation receipt if adopted through a rescue
organisation.
Name and telephone number of all local vets, rescue centres, police station and
police officers name and badge number you reported it to (if dog) or dog warden you
have contacted.
Holiday Cancellation
Claim form fully completed and signed by you (the named policyholder).
Travel operator (or similar) confirmation letter of cancellation and costs charged.
Liability
You will need to complete a Liability Claim form, please contact us to obtain a copy.
Important: Please refer to your policy terms and conditions and exclusions which shows the level of cover you have in
place for your pet and what benefits are available to you. Not all of the benefits listed here are claimable on certain
policies.
