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Claim_Form_AK_OTHST - V PI PET INSURANCE CLAIM FORM NO...

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VPI PET INSURANCE CLAIM FORM NO COVER SHEET NECESSARY. Fax to: 714-989-5600 No.of pages: Take this form to your veterinarian to complete Section 2. Veterinarian’s signature not required. TOTAL AMOUNT SUBMITTED 3 $ POLICYHOLDER SIGNATURE and DATE 4 X / / VPI DOCUMENT CENTER USE ONLY CLAIMS NOTES (VPI use only) You must submit receipts for all veterinary service charges. All submitted fees may not be eligible for coverage. Fees that exceed benefit schedule limits are your responsibility. By signing this Claim Form, I confirm that to the best of my knowledge the information I have provided is true and correct. I authorize the release of my pet's medical records to Veterinary Pet Insurance Company/DVM Insurance Agency. POLICY NO : PET NAME : BREED: AGE: NAME : ADDRESS: CITY: STATE: ZIP: PHONE (H): PHONE (B): EMAIL: POLICYHOLDER INFORMATION 1 2 / / / / WELLCARE TREATMENTS TREATMENT DATE HOSPITAL/ CLINIC / / / / / / / / Annual Exam Annual Lab Tests Vaccinations Dental Spay/Neuter Heartworm/Flea Medication FAX: (Preferred Method) 714-989-5600 MAIL:
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