Aon Pet Insurance Plan Application form

Aon Pet Insurance Plan
Application form
Policytaker information
Name: _______________________
First Name:
____________________
Date of birth:
______________________
Full address:
_________________________________________________________________________________
_________________________________________________________________________________
Post Code:
______________
City:
_______________________
Customer ID :
_________________
Pet information
Name : ______________________________________
Date of birth:
_____/______/____________
Species/Breed type:
Tattoo number:
________________________________
_______________________________
I hereby declare to be willing to subscribe to the Accident/Illness cover of Aon’ Pet Insurance Plan and pay the relevant premium by either:
‰ Annual or biannual cheque to the order of Aon Assurances
‰ Direct debit on my bank or postal account (please complete the debit authorization below)
Please indicate your pet's age and the desired payment frequency in order to allow for your initial premium to be
calculated at enrolment date:
Premium
Pet age
‰ Less than 2 years
‰ 2 or 3 years
‰ 4 or 5 years
‰ 6 or 7 years
‰ 8 or 9 years
‰ Annual
198 €
222 €
246 €
282 €
318 €
‰ Biannual
104 €
116 €
128 €
146 €
164 €
‰ Quarterly
52 €
58 €
64 €
73 €
82 €
‰ Monthly
18 €
20 €
22 €
25 €
28 €
I hereby declare to have taken due notice of the general conditions n° 20000418960087 governing the insurance product sold by Aon as "Assurance
santé chiens chats" and written with Axa France IARD and attest that my pet complies with the underwriting requirements in terms of age,
tattooing and vaccination provided at the back of this form. My contract is written for a period of one year from: __/__/____ *, and is subject to
year after year automatic renewal. I enclose with the hereby form a copy of the pet's vaccination record and my remittance cheque (or the fully
completed direct debit authorization as the case may be).
Date
__/__/____
Policytaker's signature and manuscript "read and approved" mark:
The personal information that you provide herein will for contractual purpose undergo computerized processing by Aon Conseil & Courtage. By virtue of the (French) Act of 06/01/1978
(amended), you retain a right to cause Aon Conseil & Courtage to allow you to accede, modify or remove your electronically recorded personal information. This contract is offered by Aon
Conseil & Courtage Société de courtage en assurances et réassurances immatriculée au Registre Unique des Intermédiaires d’Assurances sous le n° 07 001 560 SA au capital de 4 141 334
euros - 414 572 248 RCS Nanterre - Siège social : 45, rue Kléber - 92697 Levallois-Perret cedex Tél. 33 (0)1 58 75 75 75 - Fax 33 (0)1 58 75 77 77 - www.aon.fr - N° de TVA
intracommunautaire : FR 22 414 572 248 GARANTIE FINANCIÈRE ET ASSURANCE DE RESPONSABILITÉ CIVILE PROFESSIONNELLE CONFORMES AUX ARTICLES
L512-7 ET L512-6 DU CODE DES ASSURANCES
Contrat d’assurance à aliments souscrit auprès de la compagnie d’assurance AXA France IARD Société Anonyme au capital de 214 799 030 € - 722 057 460 R.C.S. Paris – Siège social : 26
rue Drouot 75009 Paris - sous le N° 20000418960087
* In case of accident, the cover shall commence at the earliest at the date of despatch of the documents, as attested by the postal stamp. In case of illness, the cover shall commence 45 days
after the date of despatch of the documents.
Please send your documents to Aon Assurances UPI 40-500 - 45, rue Kléber F-92697 Levallois-Perret Cedex (France)
Autorisation de prélèvement (merci de joindre un relevé d’identité bancaire, postal ou de caisse d’épargne)
Nom, prénom et adresse du titulaire
Désignation de l’organisme créancier :
Aon Conseil et Courtage
45 rue Kléber
92697 Levallois Perret Cedex
Code émetteur 45 91 18
___________________________________________________
___________________________________________________
Je vous prie de bien vouloir débiter, sans autre avis, à la condition qu’il présente la provision nécessaire mon compte ci après, du
montant de tous les avis de prélèvement qui seront émis par Aon Conseil et Courtage :
Code banque
Code guichet
Numéro de Compte
Clé RIB
Etablissement tenant le compte :
________________________________________________
Il est entendu qu’en cas de litige, je devrai régler le différend avec l’organisme
financier désigné ci-contre. Vous n’aurez pas à m’aviser de l’exécution desdites
opérations hors de l’extrait de compte que vous m’adresserez, ni éventuellement de leur
non exécution.
Adresse de l’agence
Date
________________________________________________
_________________________________________________
Signature
Pet Insurance Plan N° 20000418960087 – Extracts of General Conditions
At the anniversary date following the 15th anniversary of the
Definitions:
pet, the preceding year's premium shall be increased by 25%.
Accident: any sudden event whose cause is extraneous to the
The premium and any related accessories and taxes shall have
pet's organism and beyond the control of the insured or the
to be paid not later than ten days from the due date indicated
persons living under the same roof.
in the Particular Conditions.
Illness: any impairment of the pet's health condition observed
If you have opted for the direct debit procedure, please note
by a Veterinarian.
that this direct debit shall be stopped as soon as an instalment
will remain unpaid, and the total premium, under deduction of
Underwriting conditions
the instalments already paid, shall then become immediately
Your pet must be more than three months and less than ten
payable. Subsequent premiums shall thereafter be paid
years old at the time of commencement of the covers afforded
according to the annual payment option.
in your insurance contract. Your pet must not be affected by
acute illness and/or chronic disease nor by "deficiencies".
Exclusions
No liability shall attach hereunder and no indemnity (whether
It is mandatory that your pet be tattooed and that its
for death or illness benefit) shall be paid for expenses arising
vaccination record be valid and updated for the following
from incurred as a result of or paid for :
diseases and illnesses:
- any medical procedure or care performed by a
Dog: leptospirosis, viral gastroenteritis, rubarth hepatitis,
practitioner who is not duly registered with the
distemper disease, rabies, parvovirosis.
Veterinarians Regulatory Board (French "Ordre");
Cat: typhus, coryza, rabies, cat leucosis, calicivirosis.
- any deficiency, disability, malformation or congenital
disease of the insured pet and the consequences thereof
Activation of covers
including:
Coverage shall be granted:
ƒ hip dysphasia for all types of species or breeds;
a) In case of accident: immediately
ƒ chronic patella luxation and tear staining
b) In case of illness: the cover shall be granted for any illness
(epiphora) of little dogs;
whose first occurrence takes place after a waiting period
ƒ adnexal surgery aiming at rectifying eyelid
(elimination period) of 45 days from date of effect of the
malformation ;
contract.
ƒ milk teeth extraction for less than 1 year old pets ;
- any injuries consequent on organised dog fighting;
Territorial scope
- pregnancy, whelping and caesarean section non
The covers granted under this contract shall apply in France
consequent on therapeutical indication ;
and everywhere else worldwide during any non-professional
any
surgery operated for cosmetic purposes or aiming
sojourn of less than 3 months.
at mitigating or removing defects or anomalies (tail
docking, ear cropping) ;
Indemnity cap
any
behavioural pathologies ;
Subject to the expenses actually incurred, the maximum
purchase
of any food including dietetic food or vitamins;
liability of the insurer shall be set at EURO 2,000 per
purchase
of
antiparasitic products, lotions and
annum at enrolment.
shampoos
;
Should the contract be renewed, the above maximum annual
- dental prosthesis and any other orthotics and
limit of liability shall be increased by 5% at each main
prosthetics ;
anniversary date.
from
pet contraception and castration non consequent
Particular conditions - Limits
on
therapeutical
indication ;
Preventive procedure (vaccination
€ 70 per annum
tattooing
;
recall before the pet is 2 years old)
- vaccination and vaccines (except in case of preventive
Contribution to burial or cremation
€ 100
measure such as vaccination recall before the pet is 2
expenses.
year old and subject to the annual limit of indemnity);
Refund of pet kennel expenses incurred
€ 250 per annum
- consequent on any accident or illness occurred from or
in case of pet's owner hospitalisation
caused by or happening through:
Travel or holiday cancellation expenses
ƒ war (whether civil or foreign),
€ 250 per annum
consequent on pet's hospitalisation
ƒ riots and civil commotion
Refund of advertising expenses in case
ƒ disintegration of the atomic nucleus
€ 100 per annum
of pet loss or theft
ƒ bad treatment or lack of care attributable to the
Off indemnity lumpsum and refund basis
insured or any person living under the same roof ;
Market value at day of
th
consequent
on any accident occurred prior to the date of
Death prior to pet 8
death (up to € 800
subscription
of the contract ;
anniversary
maximum)
- consequent on any disease or pathological condition
whose first occurrence was evidenced prior to the date
Deductible
of subscription of the contract ;
The contract provides for a deductible of up to 25% of eligible
- consequent on diseases which could have been avoided
expenses. Such deductible shall be applied to each refund.
with the necessary preventive vaccinations, e.g.:
- Dog: distemper disease, rubarth hepatitis,
Premium determination over time
leptospirosis and viral gastroenteritis ;
The premium shall be determined on the basis of the pet's age
- Cat: typhus, coryza and cat leucosis.
at enrolment. It shall thereafter be increased by 5% at each
anniversary date simultaneously with the increase applied to
the insurer's maximum liability (i.e. € 2,000 at enrolment).