Wufoo

Owners name #1 * Title First Last Suffix
Ignore "suffix"...
Owners name #2 (if applicable) Title First Last Suffix
Ignore "suffix"...
Street address and suburb/town *
Post Code
City
Telephone *
Cellphone
Email address *
PETS INFORMATION (please note each pet needs a seperate application form).
Pets name *
Date of birth (approximately) *

We need the year and hopefully the month your pet was born in order to work out their exact age at date of application.
Sex *
Male Female

This provides optional cover for Funeral Cover. A small extra premium applies for this extra cover. For more information, please see www.petsonthenet.co.nz/additional
Breed/s of cat or dog *

Please state all known breed/s of this dog or cat. For cats of no specific purebreed; moggie, Domestic Short Hair (or long or medium hair), is fine. Moggies to purebreeds we love them all. NO breed is excluded from Ellenco, cats OR dogs.
Last vaccination date (approx) *

Vaccination IS NOT required to be accepted for Ellenco. If you have chosen not to vaccinate, we respect your choice, please just state "choose not to vaccinate" or similar here. Please note if you do not vaccinate and your pet becomes ill from an illness prevented by standard vaccinations, that illness will not be covered.
Plan chosen *
Base Ultra Premier Jade Silver surgery Bronze surgery

Please see petsonthenet.co.nz/petinsurance for links to all the plans benefits and premiums
Would you like to add Inherited Conditions cover?
No Inherited Conditions cover Yes, please add Inherited Condiitons cover

This provides optional cover for Inherited Conditions. A small extra premium applies for this extra cover. For more information, please see www.petsonthenet.co.nz/additional
Would you like to add funeral cover?
No funeral cover Yes, please add funeral cover

This provides optional cover for Funeral Cover. A small extra premium applies for this extra cover. For more information, please see www.petsonthenet.co.nz/additional
Has this pet been seen by a veterinarian for anything othr than routine vacinnations and de-sexing? ie allergies, skin or ear infections etc
No Yes

This provides optional cover for Funeral Cover. A small extra premium applies for this extra cover. For more information, please see www.petsonthenet.co.nz/additional
If your pet has had treatment, please provide full details or diagnosis of treatment/s
Date of treatment/accident dd/mm/yy
Is further treatment expected?
No Yes

This provides optional cover for Funeral Cover. A small extra premium applies for this extra cover. For more information, please see www.petsonthenet.co.nz/additional
If yes, further treatment is expected, what are the details of the further treatment?
Have any of the above led to your pet having a chronic/ongoing condition?
No Yes

This provides optional cover for Funeral Cover. A small extra premium applies for this extra cover. For more information, please see www.petsonthenet.co.nz/additional
Please state the name of the condition/s
Pets Veterinary Clinic Name

You may use ANY vet for treatment, however please tell us who is your pets normal vet. If your pet is new or you have not decided on a vet, please advise the vet you think you will use. You can always advise us of a change of vet later on.
Veterinary Clinic Address
Veterinary Clinic Phone Number
Please state name of a family member or friend with their daytime contact number

In cases where people move address (which they do a lot..!) and should they forget to advise us their change of address; this information is purely used as a second point of contact to find your new address (if our mail is returned to sender). We will not otherwise contact your friend or family member for any reason.
Other additional information
DECLARATION: Please type ACCEPT to indicate you have read, understood and accepted the declaration above (in the blue box above this application form) *

It is required that you read and accept the DECLARATION in the blue box above this application form in order to commence insurance. Please indicate your acceptance by typing the word ACCEPT in the box
Are you already an existing client of Ellenco pet medical insurance with another pet, prior to this application? *
No Yes, current client I am applying for more than one pet today

Please note Visa or Mastercard and Cheque/invoice options are not available for monthly payment frequencies. Only quarterly, half yearly and annual frequencies may be chosen for this payment method.

For auto payments we will post out the appropriate form
For electronic payment (via internet or phone banking) we will advise policy number and bank details to you)
PAYMENT METHOD *
Cheque Direct Debit Electronic payment Visa or Mastercard

Please note Visa or Mastercard and Cheque/invoice options are not available for monthly payment frequencies. Only quarterly, half yearly and annual frequencies may be chosen for this payment method.

For direct debits we will post out the appropriate form
For electronic payment (via internet or phone banking) we will advise policy number and bank details to you)
Frequency of payment *
Monthly (direct debit only) Quarterly Half Yearly Annually
Do Not Fill This Out