LuckyandLoyal.com

Pet Insurance Reimbursement Form

Policyholder Information:

Name: ___________________________________________
Address: _________________________________________
City: ______________________ State: _____ Zip: ______
Phone: __________________________________________
Email: ___________________________________________

Policy Number: __________________________________

Pet Insurance Company:_________________________

Pet Information:

Pet’s Name: _____________________________________
Breed(s): ___________________________________________
Age: _____________________________________________
Gender: _________________________________________

Veterinarian Information:

Clinic Name: ______________________________________
Veterinarian’s Name: ______________________________
Address: _________________________________________
City: ______________________ State: _____ Zip: _______
Phone: __________________________________________

Treatment Information:

Date(s) of Treatment: _______________________________
Date of Diagnosis: __________________________________

Veterinary Visit Total Amount Paid: $________________
Brace Durable Medical Equipment: $________________

*PAYMENT HAS BEEN PROVIDED BY PET OWNER*

Conditions (Check all that apply):

• Osteoarthritis 
• IVDD
• Hip Dysplasia
• Dog Back Pain
• Balance Issues
• Weakness
• Hypertrophic Osteodystrophy
• Luxating Patella
• Neuropathy
• Obesity Related Disorders
• Diabetes
• Osteochondritis Dissicans
• Panosteitis
• Post Surgery Rehabilitation Support Including CCL/TPLO
• OTHER___________________________________________________________________________________________________________________________________________________________________________

Veterinarian’s Signature: ______________________________ Date: __________

Veterinarian’s Name: _________________________________

*Insurance is never a guarantee of benefits