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VPI Pet Insurance Claim Form

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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.

1 POLICYHOLDER INFORMATION

POLICY NO.

PET NAME:

BREED:

AGE:

NAME:

ADDRESS:

CITY:

STATE: ZIP:

PHONE (H):

PHONE (B):

EMAIL:

2 WELLCARE TREATMENTS

WELLCARE TREATMENTS

Annual Exam

Annual Lab Tests

Vaccinations

Dental

Spay/Neuter

Heartworm/Flea Medication

TREATMENT DATE

HOSPITAL/CLINIC

5 DIAGNOSIS(ES)

Please provide a diagnosis, or a tentative diagnosis, not a description of services performed.

3 TOTAL AMOUNT SUBMITTED

$

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.

4 POLICYHOLDER SIGNATURE and DATE

5 SUBMISSION OPTIONS

FAX: 714-989-5600 (Preferred Method)

MAIL: VPI Claims Department, PO Box 2344, Brea CA 92822

To download claim forms: petinsurance.com/forms

QUESTIONS? Customer Care Dept: 800-540-2016

VPI DOCUMENT CENTER USE ONLY

CLAIMS NOTES (VPI use only)

CLAIM FORM CHECKLIST

I entered in my policy number, pet information and my contact information.

This claim form includes only one pet.

My veterinarian helped me complete Section 2 with the diagnosis(es), treatment date and the name of the hospital/clinic.

I included all of my itemized and legible receipts/invoices.

My pet's name and policy number are clearly identified on each receipt/invoice.

I added up all my eligible receipts and entered the Total Amount Submitted.

I signed and dated this claim form. (My veterinarian is not required to sign this form.)

I submitted this claim form and all supporting receipts/invoices to the VPI Claims Department. I understand that claim forms that are incomplete or missing itemized and legible supporting receipts/invoices may be delayed.

I kept a back-up copy of all documentation submitted for my records.

If medical records are requested to process this claim, I understand that it is my responsibility to provide them to VPI.

Applicable in New York: 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.

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What the VPI Pet Insurance Claim Form Is and When It’s Used

The VPI Pet Insurance Claim Form is the standard document policyholders use to request reimbursement for covered veterinary care. It collects owner and pet identification, policy number, provider details, diagnosis and treatment dates, itemized invoices, and payment instructions. Submissions may be made by mail, email, portal upload, or electronic signature where accepted; electronic submissions must meet legal requirements under the ESIGN Act (15 U.S.C. ch. 96) and applicable state UETA or ESRA rules. Accurate, complete claims help speed review and reduce processing delays for eligible expenses.

Why Accurate Claims Matter for Faster Reimbursement

Completing the VPI Pet Insurance Claim Form correctly reduces processing time, lowers the chance of denials, and creates a clear record for audits or tax purposes. Electronic submission with an auditable signature and receipts supports legal validity under ESIGN and state e-signature statutes, and simplifies follow-up with veterinary providers and the insurer.

Why Accurate Claims Matter for Faster Reimbursement

Who Typically Completes or Signs This Form

In some cases a clinic or agent may submit on the policyholder's behalf with written authorization; retain copies for your records.

  • Pet owners: Provide policy details, sign authorizations, and attach itemized veterinary invoices.
  • Veterinary clinics: Supply treatment codes, dates, itemized billing, and provider contact information.
  • Insurance agents or administrators: Review submissions, confirm coverage, and process reimbursements on behalf of policyholders.

Roles Who Interact With the Form

Primary Policyholder

The policyholder is the payer on record who must provide accurate name, policy number, contact information, and a signature or consent for electronic submission. Mismatched names or missing authorization commonly delay processing and may require proof of identity before reimbursement.

Veterinary Provider

The treating veterinarian or clinic supplies diagnosis, treatment codes, dates of service, itemized charges and a provider signature or official stamp. Timely, itemized invoices that match the claim form expedite adjudication and reduce requests for additional documentation.

Essential Information Fields to Include

Policy Number: Unique insurer account identifier.
Pet Information: Name, species, breed, age, and ID.
Owner Contact: Full name, phone, email, address.
Veterinary Details: Clinic name, address, phone, NPI if available.
Service Dates: Exact dates of treatment provided.
Itemized Charges: Detailed invoice line items and totals.

Step-by-Step: Completing the Claim Form

Follow these steps to prepare a complete VPI Pet Insurance Claim Form for faster adjudication and payment.

  • 01
    Gather documents: Collect itemized invoices, medical records, and receipts.
  • 02
    Enter policy data: Fill policy number, owner name, and contact details.
  • 03
    Provide treatment details: List diagnosis, procedures, dates, and provider info.
  • 04
    Sign and submit: Add signature and preferred payment method, then send.

How to Prepare an Online Claim Submission Workflow

Configure an online submission to collect required fields, attachments, signature, and routing to VPI or a designated email address.

Field Configuration
Required Fields Policy, owner, pet, dates, invoices
Attachments Allow PDF, JPG, PNG uploads
Signer Authentication Email code or multi-factor preferred
Routing Send to insurer portal or claim email

Submission Flow: From Form to Reimbursement

Understand the typical routing so you can track the claim and respond to requests for more information promptly.

  • Prepare claim: Complete form, attach itemized receipts.
  • Sign: Add wet or electronic signature with authentication.
  • Submit: Upload to insurer portal or email claims address.
  • Adjudication: Insurer reviews, may request clarifying documents.

Digital Signing and Submission: Platform Considerations

Ensure the chosen platform meets the insurer's authentication requirements and your organization's privacy policies before submitting.

  • signNow: Cloud eSignature platform with audit trails and integrations.
  • File formats: Accepts PDF, DOCX, JPG for attachments.
  • Integrations: Works with Google Workspace and Microsoft 365

Typical Deadlines and Timing Expectations

Timelines vary by policy; confirm VPI's specific submission window in your policy. Below are common timing considerations to plan for.

Submission window:

Many insurers request claims within 90–180 days of treatment; verify your policy.

Processing time:

Insurer review commonly takes 7–30 business days once complete documentation is received.

Receipt retention:

Retain originals for at least 3 years for tax purposes (IRS guidance).

Follow-up timeframe:

Expect insurer to request clarifications within 30 days of receipt.

Dispute period:

Policies typically define an appeal period; consult your policy for exact limits.

Common Preparation Mistakes That Cause Delays

  • Submitting an unsigned form or missing provider signature leads to automatic follow-up and processing delays.
  • Providing a summary invoice instead of an itemized invoice prevents validation of line items and can cause partial or denied payments.
  • Entering an incorrect policy number or owner name causes account mismatch and requires manual correction before payment.
  • Uploading illegible scans or incorrect file types forces re-submission and slows adjudication.

Risks of Incomplete or Incorrect Claims

Claim denial: Missing or inconsistent data can result in denial.
Payment delay: Incomplete attachments cause extended processing time.
Duplicate claims: Resubmissions without tracking can trigger duplication.
Tax complications: Insufficient records complicate deduction substantiation.
Privacy risk: Unsecured transmission may expose PHI if not protected.
Appeal burden: Incorrect denials require time-consuming appeals.

Key Sections That Make a Professional Claim Form

A complete VPI Pet Insurance Claim Form includes discrete sections designed to support review, audit, and payment. Each section aligns with insurer requirements and legal expectations for electronic records.

Claimant Details

Full policyholder name, mailing address, phone, email, and policy number so the insurer can match the claim to the correct account and contact the claimant for follow-up.

Pet Information

Pet name, species, breed, birthdate, and identification. Clear pet identifiers prevent confusion across multiple enrolled pets on the same policy and aid record matching.

Provider Information

Veterinary clinic name, address, phone, and provider ID where available. Provider contact information allows quick verification of charges and treatment details.

Treatment Summary

Diagnosis, procedures performed, medications administered, and concise clinical notes. This narrative supports coverage determinations and helps triage urgent claims.

Itemized Billing

Line-by-line invoice showing services, codes, quantities, and amounts. Itemized bills are required to validate reimbursements against policy limits and exclusions.

Authorization & Signature

Policyholder signature or electronic consent, date, and payment instructions. Proper attribution and intent evidence satisfy ESIGN’s legal validity criteria.

Supporting Documents and File Handling Best Practices

Include the correct supporting documentation and follow file format best practices to prevent unnecessary review delays.

Required Attachments

Attach itemized veterinary invoices, medical records when requested, proof of payment if pre-paid, and any referral or authorization documents.

File Formats

Use high-quality PDF scans when possible; JPG or PNG accepted for photos. Ensure each file is legible and not password-protected.

Scan Quality

Scan at 200–300 DPI, crop excess background, and confirm text is readable to avoid re-submission requests.

Naming Conventions

Label files clearly (e.g., 'Invoice_ClinicName_MMDDYYYY.pdf') so insurer reviewers can match attachments to form sections quickly.

Frequently Asked Questions About the VPI Pet Insurance Claim Form

Answers to common questions about submission, signatures, documentation, and what to do if a claim is denied.


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