Equine Claims Wizard

Policy Number:

(Payment can be made directly to the Veterinary Clinic or Policyholder)

Account Name:

Account No:

Bank Name:

Account Type:

Branch Code:

Horse’s Name:

Has the horse fully recovered?

Yes No

Describe fully what happened:

When was the horse first discovered to be sick or injured?

Please select the date:

Please select the time (Optional):

What treatment did the animal receive prior to Veterinarian’s arrival, and by whom?

When was the veterinarian notified of the event?

When was the veterinarian first in attendance?

When was Arco 360 notified of the sickness or injury?

Were subsequent visits made?

Yes No

If yes, confirm the follow-up dates to correspond with the dates on the invoices submitted (Leave blank if not applicable)

1st Invoice Date:

2nd Invoice Date:

3rd Invoice Date:

4th Invoice Date:

5th Invoice Date:

6th Invoice Date:

7th Invoice Date:

8th Invoice Date:

Has the animal undergone any surgical operation in the duration of this policy?

Yes No

If yes, please provide details and Name of Attending Vet for above surgery:

Have any other horses in your ownership died in the past 3 years?

Yes No

If yes, please provide details in the space provided below and specify whether insured or not.

Apart from the insurance to which this Claim Form refers, is there any other insurance pertaining to this animal?

Yes No

If yes, provide details.

Other Insurance(s):

Insurer(s):

Policy No.(s):

I do solemnly and sincerely declare that the foregoing particulars are true and correct and that the claim is a just and reasonable one. I further declare that the proper treatment and care was given to the animal. I acknowledge that in the event of any of the above answers or part thereof be untrue, my claim for compensation shall be forfeited and the said Policy shall be null and void.

Declared at (city/town)

on the (day)

of (month)

year

Please sign in the block below or upload a scanned copy of your signature:

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Equine Claims Wizard

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