Veterinary Claims

It is our understanding that you have provided veterinary services to a policyholder of ours. In order to make a claim for the renumeration of your fees we ask that you complete the below form.

Once you have completed all of the requested details and submitted the form, you will receive an e-mail requesting that you supply any supporting documentation by way of reply.

All questions are mandatory unless marked '(Optional)'

Policy details

To whom is the claim being paid?

Referral details

Who referred the animal to you?

Condition details

Do you know the date that the animal was taken ill or was injured?

Are further conditions involved in this case?

Do any of the conditions relate to each other?

Has the animal suffered from the condition(s) before?

Which diagnosed condition has the animal suffered from previously?

Can this current condition be indirectly or directly related to any previous accident or illness?

Have you referred the animal to another practice for any further diagnostics and/or treatment(s)?

Treatment details

Have you recommended any box rest? (Optional)

Have you recommended any complimentary treatment(s) (e.g. physiotherapy, farrier)? (Optional)

Please select the complimentary treatment(s) you have recommended:

Have all treatment(s) been completed?

Are you able to estimate to total cost of treatment?

Will the animal require any further treatment(s)?

Diagnosis details

Has the animal died?

Could the condition lead to a Loss of Use Claim?

Loss of animal details

Was the animal euthanised?

Was the animal euthanised by you?

Was the animal euthanised in accordance with BEVA guidelines:

Were there any other viable treatment options available?

Could the animal have been clinically retired to paddock with the condition?

In your opinion was the condition referred to above the sole reason for euthanasia?

Did you see the animal before it's death?

Has a post-mortem taken place?

We'll ask you to e-mail the post-mortem to us

After you have submitted this form you will receive a confirmatory e-mail. We ask that you attach the post-mortem that was carried out on the animal to your reply. 

Review of claim

Please review the details of the claim that you have provided in the previous steps. If there is anything that you would like to change, you can navigate back to the relevant step using the navigation bar. 

Policy details

Claim number:

Policyholder's name:

Animal's name:

Claim paid to:

Referral details

Animal referred by:

If other veterinary referral -
Name of veterinary practice:
Veterinary practice branch/postcode:
Name of veterinary surgeon:
Email address of veterinary surgeon/practice:

Condition details

Date animal taken ill or injured known:

If date known -
Date animal taken ill or injured:

Date of first examination for this condition:

Date animal was registered at your practice:

Reason for referral:

Pathology that forms first condition:

Type of condition (where applicable):

Details related to condition (if requested): 

Further conditions involved in case: 

If secondary diagnosis made - 
Details of other conditions:
Condition related to each other: . If related, how: 

Animal suffered from condition previously:

If suffered from condition before and secondary diagnosis made -
Which diagnosed condition suffered before:

If suffered from condition previously -
Treatment previously provided for condition: 
Treatment for previous occurence of condition administered:

Current condition indirectly or directly related to any previous accident or illness: 

If current condition indirect or directly related to any previous accident or illness -
How related:

Details of diagnostic techniques carried out: #DiagnosticTechniquesDetails#

Animal referred to another practice for any further diagnostics and/or treatments(s): 

If referred to another practice for any further diagnostics and/or treatments(s) -
Name of veterinary practice:
Veterinary practice branch/postcode:
Name of veterinary surgeon:
Email address of veterinary surgeon/practice:

Treatment details

Details of treatment(s) you have recommended:

Box rest recommended:
If box rest recommended -
Duration of box rest recommended:

Complimentary treatment(s) recommended:

If complimentary treatment(s) recommended -
Type of complimentary treatment(s) recommended:  

Treatment(s) completed:
If treatment(s) completed -
Cost of treatments:
If treatment(s) not completed -
Estimated cost of treatment(s):
Further treatment(s) required:

Diagnosis details

Animal died:

If animal has not been put to sleep -
Could condition lead to a Loss of Use claim:
Details of why condition could lead to a Loss of Use claim:

Loss of animal details (if animal has passed away or been put to sleep)

Animal euthanised:

If animal put to sleep -

Animal euthanised by claiming vet:

If animal not put to sleep by claiming vet: 
Details of person who euthanised animal:
Euthanaised in accordance with BEVA guidelines:

If not euthanised in accordance with BEVA guidelines -
Euthanisia not in accordance with BEVA guidelines explanation:

Other viable treatments options available:

If other viable treatment options available -
Treatment options and why not pursued:

Could the animal have been clinically retired to paddock:

If animal could have been clinically retired to paddock -
Why horse wasn't retired to paddock:

If animal not euthanised -

Animal seen before death:

If animal not seen before death -
Animal last seen prior to death:

Post-mortem taken place:

If post-mertem has taken place - 
Actual cause of death:

Both euthanised and non-euthasised - 

Date of death or euthanasia:
Time of death or euthanisia:

After reviewing and if you are happy with the details that you have provided please advance to the next step of this web form. 

Declaration and veterinary details

I hereby certify that I have checked that all of the details submitted are, to the best of my knowledge and belief, true and correct: