Claim Form - Puppies for Sale Salt Lake City

Name(Required)

First Last

Email(Required)

Enter Email Confirm Email

Phone(Required)

Date of Purchase(Required)

Invoice / Contract Number

If known

Puppy Name(Required)

Puppy Breed(Required)

Puppy Sex

Male

Female

Puppy Date of Birth

Microchip Number

AKC / Registration Number

Trupanion Policy / Member Number(Required)

Trupanion Claim Number(Required)

Date of Vet Service(Required)

Veterinary Clinic Name

Enter these from your Trupanion Explanation of Benefits (EOB).

Total Vet Bill(Required)

Amount Trupanion Paid(Required)

Your Deductible(Required)

Your 10% Co-pay(Required)

Total Reimbursement Requested

Automatically calculated: your deductible + your 10% co-pay.

Accepted files: jpg, png, pdf (max 20 MB each).

Itemized Veterinary Invoice(Required)

Accepted file types: jpg, png, pdf, Max. file size: 20 MB.

Trupanion Explanation of Benefits (EOB)(Required)

Accepted file types: jpg, png, pdf, Max. file size: 20 MB.

Proof of Payment (receipt or statement)(Required)

Accepted file types: jpg, png, pdf, Max. file size: 20 MB.

Authorization(Required)

I authorize Puppies for Sale Salt Lake City to verify these amounts with Trupanion if needed.

Certification(Required)

I certify the information provided is accurate and complete.

Signature(Required)

Type your full name as your signature.