Pet Insurance Enrollment Form - SHN

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Tell Us About Your Pet(s)

Warning: All pets, regardless of species, must be on the same type of plan (Accident & Illness OR Accident & Illness with Wellness). If you enroll pets on different plan types, you will be asked to amend your elections.

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Row ID	Name of Your Furry Friend	Dog or Cat?	Protect Your Furry Friend (Dog)	Protect Your Furry Friend (Cat)	Actions

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Wrapping Up

Terms and Conditions(Required)

Pets 11 years and older are not eligible for coverage. If your pet is already enrolled in a PetPartners plan and turns 11+, they will continue to have coverage, assuming no gap in coverage.

All pets, regardless of species, must be on the same type of plan (Accident & Illness OR Accident & Illness with Wellness). If you enroll pets on different plan types, you will be asked to amend your elections.

Pre-Existing condition coverage may require a 365-day waiting period. The waiting period may be waived for groups with over 200 employees or with prior coverage for Accident & Illness plans. Participation in this plan is voluntary and not subject to ERISA.

Eligible with optional Alternative & Behavioral Care rider. Policies are administered by PetPartners, Inc. and underwritten by Independence American Insurance Company (rated A- “Excellent” by A.M. Best), with offices at 11333 N. Scottsdale Rd, Suite 160, Scottsdale, AZ 85254. PetPartners, Inc. (CA agency #OF27261) is a licensed insurance agency located at 8051 Arco Corporate Drive, Suite 350, Raleigh, NC 27617. Eligibility restrictions apply. Terms and conditions may apply. See policy/certificate for details on coverage, terms, limitations, and conditions.

Waiting periods, annual deductible, co-insurance, benefit limits, and exclusions may apply. For full terms, visit https://www.petpartners.com/sample-policies.

Products, schedules, discounts, and rates may vary and are subject to change. More information will be available at checkout. Insurance products are underwritten by Independence American Insurance Company (rated A- “Excellent” by A.M. Best), with offices at 11333 N. Scottsdale Rd, Suite 160, Scottsdale, AZ 85254. PetPartners, Inc. (CA agency #OF27261) is a licensed insurance agency located at 8051 Arco Corporate Drive, Suite 350, Raleigh, NC 27617. Eligibility restrictions apply. Terms and conditions may apply. See policy/certificate for details on coverage, terms, limitations, and conditions.

I understand that pets aged 11 years and older are not eligible for enrollment. I also understand that all pets, regardless of species, must be on the same type of plan, and that I will be asked to amend my elections if I have enrolled pets on different coverages.

I am enrolling my furry friend(s) into PetPartners Pet Insurance Plan, presented by 1Life Benefits Trust and underwritten by Independence American Insurance Company. I also understand that I will be invoiced for the plan that I selected. I have read the limits and exclusions of the plan and understand.

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