Claim Form All claims must be submitted in writing within ninety (90) days of the treatment or receipt date. 1 Member Info Policy Number: Pet Parent Name: My Vet Info Address: Clinic/Vet O昀케ce City: State: Zip: Phone: Vet Name: Pet Name: - Address: Phone: 2 Vet Visit Info Email: Please attach medical records (i.e. SOAP notes, vet notes, chart notes) from your veterinarian for the claimed incident. Important Note: Medical records often di昀昀er from discharge instructions and invoices, so it is important to ask your vet speci昀椀cally for chart/SOAP/vet notes. *Please note: if this is your 昀椀rst claim, please provide 12 months of medical records. If you have recently adopted your pet and don’t have 12 months of medical records, all you will need to submit is your adoption contract. Attach invoices and/or itemized receipts along with this completed claim form. 3 Diagnosis and Invoice Info / / $ Treatment Date Medical Diagnoses or Routine Treatment Total Charges / / $ Treatment Date Medical Diagnoses or Routine Treatment Total Charges / / $ Treatment Date Medical Diagnoses or Routine Treatment Total Charges 4 Sign and Date Policyholder declaration: I declare my veterinarian recommended the treatment for which I am claiming. The particulars given are correct to the best of my knowledge and belief. I authorize my veterinarian to release medical records and give consent to MetLife Pet Insurance, to communicate with my veterinarian or veterinarian’s sta昀昀. Any person who knowingly and with intent to defraud any insurance company or other person 昀椀les 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 昀椀ve thousand dollars and the stated value of the claim for each such violation. All claims must be submitted in writing to MetLife Pet Insurance within ninety (90) days of the treatment or receipt date. Please allow at least 10 business days for processing. Incomplete forms will delay claims processing. Signature: Date: Submit Your Claim MAIL TO: MetLife Pet Insurance - EMAIL TO: FAX TO: UPLOAD TO: Claims Department, [email protected] 877-281-3348 Our Mobile App or 400 Missouri Avenue, Suite 105, MyPets Online Account Jeffersonville, IN 47130 © 2022 MetLife Services and Solutions, LLC, New York, NY 10166 - All Rights Reserved.