Pet Information

  • Pet's Name:
  • Pet Type: Dog Cat
  • Breed:
  • Birth Date: (eg.Jan 01, 2011) More Info
    Pets must be 8 weeks of age or older to be eligible for coverage.
  • Gender: Male Female
  • Tattoo/microchip number: (optional)
Pet Veterinary Information
  • Province of Primary Veterinanrian:
  • Vet Practice:
  • Vet Address:
  • My Pet's Veterinarian is not listed:
  • Practice Name:
  • Practice Phone Number:

Pet Owner Information

  • Salutation: Dr. Mr. Ms. Mrs. Miss
  • First Name:
  • Last Name:
  • Add a Co-owner:
  • Co-owner Salutation: Dr. Mr. Ms. Mrs. Miss
  • Co-owner First Name:
     
  • Co-owner Last Name:
     

Contact Information

  • Address:
  • Suite:
  • City:
  • Province:
  • Postal Code:
  • Home Phone Number:
  • Cell Phone Number:
  • Work Phone Number: Ext.
  • Email:
  • Confirm Email:
  • I prefer to be contacted by: Email Regular Mail

Declaration

I declare that:

  • All statements and particulars contained in this voucher activation are true. I understand that misrepresentations will render the insurance null and void.

  • I understand that there may be treatments not covered by this voucher as per the Voucher Terms and Conditions.

  • I authorize my veterinarian to release all medical histories to Petsecure and to confirm any details as required, and for Petsecure to advise my veterinarian of my chosen plan.

  • I have read, and agree to the Voucher Terms and Conditions .

  • I Agree:

  • I allow Petsecure to use my personal information to offer me upgrades or additional services

  • Yes No