Companion Protect - Enrollment

Zip

Pet Birthdate

Pet Type

Common Accidents:

Foreign Body Ingestion
Eye Trauma
Hit By Car
Exposure to Toxins
Insect Bites and Stings
Mouth and Tooth Injuries

Illnesses Over Time:

Cancer
Ear Infections
Skin Conditions
Allergies
Digestive Issues
Respiratory Issues
Kidney Disease
Urinary Tract Infections
Diabetes
Arthritis
Hip Dysplasia
Cruciate Ligament Injuries
And many more!

* The quote above includes selected discounts. Multi-pet, group, and employer discounts will be incorporated as applicable as we process your enrollment and are not reflected above.

* Monthly transaction fee may apply

First Name

Last Name

Email Address

Primary Phone

Alternate Phone

First Name

Last Name

Email Address

Primary Phone

Alternate Phone

Address (please include Apartment/Unit number where applicable)

City

State of Residence

Zip

Pet Name

Where did you get your pet?

Other Location

Pet Adoption Date

If adopted, what was the pet's name at time of adoption?

Provide any injury, illness or medication conditions you are aware of since your pet’s last visit.

If yes, list the conditions.

Card Number

CVV

Expiration Month

Expiration Year

Preferred Recurring Billing Day

I understand that my card will have a hold placed on it in the amount of the monthly premium and transaction fee. This hold will be cleared if the enrollment is not completed. If the enrollment is completed the card will be charged the first monthly premium and transaction fee. Ongoing monthly premium and transaction fees will be charged a minimum of twelve (12) days in advance of monthly policy period.

I understand that my card will have a hold placed on it in the amount of the monthly premium. This hold will be cleared if the enrollment is not completed. If the enrollment is completed the card will be charged the first monthly premium. Ongoing monthly premium fees will be charged 5 days in advance of monthly policy period.

Confirm your agreement to the following items:

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If Pre-existing medical conditions have been or are identified prior to enrollment, I understand they may not be covered.

I have been provided the opportunity to review the E-Sign Consent here and I consent to conducting this transaction electronically.

I agree to electronic communications for all insurance related correspondence.

Be prepared to provide medical history if available.

It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

Sign below to authorize payment and enrollment.

How did you hear about Companion Protect?

For assistance or to speak with an Animal Care Advocate, call 800-304-9930.

Companion Protect Enrollment Application

Welcome from Com-Pro Two Animal Shelter!

Lookup Your Premium

Your Quote is ----

Discounts

Pet Parent Contact Info

Secondary Contact Info (Optional)

Pet Parent Address Info

Pet Details

Pet Health Information

Payment Information

Confirmation

Authorization

Additional Questions