spot Waiting Period Health Assessment Instructions
- June 15, 2024
- SPOT
Table of Contents
Waiting Period Health
Assessment Instructions
Waiting Period Health Assessment
Waiting Period Health Assessment Form
PART ONE – PET OWNER/POLICYHOLDER TO COMPLETE
Instructions:
- Complete and sign Part One of this form.
- Arrange for a Health Assessment Exam up to 3 days before or within 7 days after your initial policy effective date.
- Have your veterinarian complete and sign Part Two of this form during your pet’s Health Assessment Exam.
- Submit this completed 3-page form to us at forms@customer.spotpetins.com within 30 calendar days of the Health Assessment Exam.
In order for us to modify the waiting period, you must meet each of the following requirements:
- A qualifying exam of your pet by a veterinarian that includes an assessment of all body systems and parts;
- the results of the exam need to be documented at the time of exam on this Waiting Period Health Assessment Form;
- the qualifying exam must occur within 3 days prior to or 7 days after your initial policy effective date; and
- the Waiting Period Health Assessment form must be provided to us at forms@customer.spotpetins.com within 30 calendar days of your qualifying exam.
If the Waiting Period Health Assessment requirements are met, the waiting period will be waived to either the policy period effective date or the day after the qualifying exam, whichever is later. This waiver does not alter the pre-existing conditions exclusion. Please refer to your policy for information about waiting periods.
Your Name:———— Phone:—————- Email: ————
Pet’s Name:———— Pet’s Breed: ——— Pet’s Age: ——- Cat Dog
- Is your pet currently sick or injured, or did they recently experience an accident, display clinical signs or symptoms, or receive treatment from a veterinarian for any reason? Yes No If yes, describe:
- Is your pet currently on any medication, supplements or prescription food? Yes No If yes, describe:
- Has your pet ever been sick, injured or treated by a veterinarian in the past? Yes No If yes, describe:
- Has your pet been seen by any veterinarian other than the one conducting this exam? Yes No If yes, who and when:
You certify that you did not make a misrepresentation to us which includes a
statement that is false, partially false, or which does not fairly reflect the
truth. You understand that if you did, we may deny your request to modify the
waiting period. You authorize any veterinarian who has ever seen or treated
your pet to provide all medical records as may require. It is a crime to
knowingly provide false, incomplete or misleading information to an insurance
company for the purpose of defrauding the company. Penalties may include
imprisonment, fines or a denial of insurance benefits.
Your Name:————Date:————
U0823-MEWP
Insurance products are underwritten by either Independence American Insurance
Company (NAIC #26581. A Delaware insurance company located at 11333 N.
Scottsdale Rd, Ste. 160, Scottsdale, AZ 85254), or United States Fire
Insurance Company (NAIC #21113. Morristown, NJ). Please refer to your policy
forms to determine the underwriter for your policy. Insurance is produced by
Spot Pet Insurance Services, LLC. (NPN # 19246385. 990 Biscayne Blvd Suite
603, Miami, FL 33132). CA License #6000188. PTZ Insurance Agency Ltd. (NPN:
5328528. domiciled in Illinois with offices at 1208 Massillon Road, Suite
G200, Akron, Ohio 44306) is responsible for administration and claims
adjudication. (California residents only: PTZ Insurance Agency Ltd., d.b.a PIA
Insurance Agency Ltd. CA license #0E36937).
PART TWO – VETERINARIAN TO COMPLETE DURING EXAM
This form must be completed on the same day as the health assessment exam, by
the Veterinarian who performed the exam.
Pet Name:———————–
Pet Breed:———————–
Pet Species:———————
Body Condition Score (1-9):____/9
Pet Age:—————-
Veterinarian’s Name and Clinic/Hospital Name:—————
Date of Exam:—————————
Clinic/Hospital Address:—————
Clinic/Hospital Phone:—————–
Clinic/Hospital Email:—————–
Does this pet have a diagnosis, clinical signs or symptoms associated with any of the following conditions? Please answer the following based on your comprehensive, in-person physical examination and assessment:
| CONFIRMED
This pet has a confirmed diagnosis either past or present| POSSIBLE
This pet has possible signs or symptoms, but no confirmed diagnosis|
NO
Addison’s Disease (Hypoadrenocorticism)| | |
Allergies| | |
Arthritis/Degenerative Joint Disease (DJD)| | |
Brachycephalic Airway Syndrome (BOAS)| | |
Cancer| | |
Chronic Renal Failure/Kidney Disease| | |
Chronic Pancreatitis| | |
Chronic Valvular Disease or Structural Heart Disease| | |
Cushing’s Disease (Hypoadrenocorticism)| | |
Degenerative Myelopathy| | |
Dental Disease: Periodontal, Stomatitis, Tooth Resorption| | |
Diabetes Mellitus (DM)| | |
Hyperthyroidism/ Hypothyroidism| | |
Hypertrophic Cardiomyopathy (HCM)| | |
Inflammatory Bowel Disease (IBD) /Chronic Enteropathy| | |
Immune Mediated Thrombocytopenia| | |
Intervertebral Disc Disease (IVDD)| | |
Ligament and Knee Conditions (CCL/MPL)| | |
Megaesophagus| | |
Wobbler’s Syndrome| | |
Other: Does this pet have any clinical signs, symptoms or diagnosis of ANY
other condition(s) not listed above?| | |
If Yes – please describe the condition(s), clinical signs or symptoms and when
they began:
PART TWO – VETERINARIAN TO COMPLETE DURING EXAM
This form must be completed on the same day as the health assessment exam, by
the Veterinarian who performed the exam.
Please select either normal or abnormal, and if abnormal describe.
| NORMAL| ABNORMAL/ PROBLEM
Eyes (if abnormal, describe):| |
Ears (if abnormal, describe):| |
Skin (if abnormal, describe):| |
Allergies (if this pet has allergies, to what/which kind?)| |
Lumps, bumps, growths, lymph nodes (if abnormal, describe type and location):|
|
Teeth and gums (if dental disease is present, what grade?)| |
Brachycephalic conformation — If pet is Brachycephalic, select abnormal (if
abnormal, does the pet have any breathing or digestive problems or has surgery
been recommended or performed?)| |
Respiratory (if abnormal, describe):| |
Cardiovascular (if abnormal, describe; if a murmur is present, what grade):| |
Neurological (if abnormal, describe):| |
Cruciate ligaments, knees (if there is laxity, pain or limping, which
leg(s)?):| |
Luxating patella (if there is luxation, which leg(s) and what grade?):| |
Orthopedic – joints, extremities (if abnormal, describe and indicate which
area(s)/joint(s)):| |
Orthopedic – back, neck, spine (if abnormal, describe and indicate location):|
|
Orthopedic – hips (if abnormal, describe):| |
I certify that I’ve taken reasonable care not to make a misrepresentation and
the answers and statements made in this form and any supporting documentation
has been answered honestly, accurately and to the best of my knowledge based
on a physical examination personally performed by me. It is a crime to
knowingly provide false, incomplete or misleading information to an insurance
company for the purpose of defrauding the company. Penalties may include
imprisonment, fines, or a denial of insurance benefits.
Veterinarian Printed Name: ___ Veterinarian
Signature: __ Date: ____
Maine Health Assessment