Pet Insurance

Pets

If you have any further enquiries regarding our insurance policies please contact our Customer Service Team on 0845 408 5908, available Monday to Friday 9.00am - 5.00pm.

Before completing this insurance proposal form please take some time to browse the Pet Insurance Key Facts Document (PDF).

Please provide your contact details

Full Name (Mr/Mrs/Miss)
Address
Address
Address
Postcode
Daytime Telephone Number
Email

Please provide details for your pet

Pet's Name

Pet Type

Pedigree Dog

Crossbreed Dog

Cat

Breed (if Pedigree)

Pet's Description

Sex

Male

Female

Please note that your pet most be over 8 weeks old and younger than 8 years.

Age Years

Age Months

Date of Birth

Date of Purchase

Purchase Price

Please provide your vet's details

Practice Name
Address
Address
Address
Postcode
Practice Telephone Number

Disclosure

Important – You must give full and true answers to all questions. If you do not do so your insurance cover may not protect you in the event of a claim. Any other facts which are known to you which are likely to affect the acceptance or assessment of this insurance cover you are requesting must be disclosed. Should you have any doubt about what you should disclose, do not hesitate to ask your insurance advisor.

The Law Applicable to this Contract
You and We are free to choose the law applicable to this policy. Your policy will be governed by the law of England and Wales unless You and We have agreed otherwise.

Data Protection Act

AXA Insurance UK plc is a member of the AXA Group. To set up and administer your Policy we will hold and use information about you supplied by you. We may send it in confidence for processing to other companies in the AXA Group (or companies acting on our instructions) including those located outside the European Economic Area.

Declaration

I declare that the statements and particulars given in this application are to the best of my knowledge and belief, true and complete and that I have read the note headed ‘Disclosure’ and I have read and understood the policy summary. Where the form has been completed in full on my behalf, I confirm that I have read and agree that it is a correct record of my answers.

I understand that signing this Application Form does not bind me to complete the insurance but agree that should a contract be concluded, this application and the statements I have made will form the basis of the contract.

I understand that the details that I have supplied may be passed to the insurer for purposes of my insurance. This includes underwriting and claims handling and could extend to passing details to other insurers for fraud prevention purposes.

I consent to the insurers having direct access to my current or previous veterinary practitioner and for them to disclose relevant information for underwriting or claims handling purposes.

This product meets the demands and needs of those who wish to ensure that the veterinary needs of their pet are met throughout the duration of the policy.

Please check this box to agree to the declaration