Insurance Form

Insurance Form

Thank you for providing your insurance information below. We will keep it on file and, if preferred, use it to submit all of your future claims and medical records directly to your insurer for reimbursement. Insurance claims are usually submitted within two weeks of your visit. If you have any questions, contact us at 312-421-2275 and ask to speak with our Pet Insurance Specialist or email claims@westloopvet.com
Choose Hospital Location
Policy Holder Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Pet's Name
Please note, you will need to complete a separate form for each insured pet in your household.
Insurance Company
(Pumpkin, Pet's Best, Healthy Paws, etc.)
Policy Number
(If you have Healthy Paws, please include the PET ID as well)
What is the name of your policy?
(Elite, Major Medical, Whole Pet, etc.)
Effective Date of Coverage

MonthDayYear
Date
Is Wellness/Preventative coverage included in your policy?
Would you like West Loop Veterinary Care to submit claims directly to your insurance, or do you prefer to submit your own claims?
Insurance Form Agreement

By submitting this form, you certify that the information provided to West Loop Veterinary Care is truthful, accurate, and complete. I understand that deliberate misrepresentation of my pet’s condition or the omission of any material facts may result in the denial of a claim and/or the cancellation of the insurance. I authorize West Loop Veterinary Care to provide to the insurer any details it may require to complete this claim, including but not limited to, all medical records, including those from outside facilities. While we provide our best service to assist you with your insurance needs, West Loop Veterinary Care will not be held liable for the outcome or denial of any claims.
West Loop Veterinary Care cannot retroactively submit claims more than 90 days past the date of service.
Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
Upload a copy of your insurance DECLARATIONS page:

(Most insurance companies will email you these documents shortly after your enrollment, and can be found as an attachment in your welcome packet.)
Cancelof
Signature
Date

MonthDayYear
Date
Should be Empty: