Dog and Cat Insurance
Application form.

DOGS AND CATS IN THE UK AND CHANNEL ISLANDS ONLY


PHA Pet Insurance.
89 Station Road, Sidcup,
Kent, DA15 7DN, UK

This form is an application for Insurance.

Click here for details of Cover, Premium details or Dog and Cat Home Page

To apply for Insurance please complete and submit the following form. Cover will start as soon as we acknowledge receipt.

Should you experience any problems simply telephone (during office hours) to apply over the telephone quoting PHA

PET NAME:

Dog or Cat
 Male or Female

Pet Breed
Purchase Price
Pet Date of Birth
(your pet must be between 8 weeks to 8 years at the start of the policy, however, the policy can be continued for life.)


Excess Level chosen?
£40 or £70


Have any of the animals received veterinary treatment other than routine vaccinations?
Yes No


Has a complaint been made regarding any of the above animals?
 Yes No

Do any of the above animals have vicious tendencies?
 Yes No

Are any of the above animals used in connection with any trade or business?
 Yes No

Have you been hospitalised for more than four days on any occasion during the past 5 years?
 Yes No


If you have answered yes to any of the above questions please supply details:



About yourself

Mr/Ms/Mrs

Surname

First name


Address

Postcode

E-mail:(Required)
Contact Telephone number



Please specify your preferred method of payment:
Cheque
Credit/debit card
Monthly Direct debit (no extra charge)

Healthy Pets is an Independent Pet Insurance Intermediary.
Head Office: The Brickyards, Steep Marsh, Petersfield. HAMPSHIRE GU32 2BN
e-mail: sales Tel: quote PHA
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