100X Colic Surgery Coverage

Surgical Reimbursement Claim

We are sorry your horse went through this. This claim, together with your veterinarian’s Program Compliance Affidavit and your documentation, starts the reimbursement review.

Deadlines: notify 100X Equine within 14 calendar days of the date of surgery, and submit this claim and the veterinarian’s affidavit within 14 calendar days of the date of discharge from the surgical facility. Incomplete submissions delay review. False or fraudulent claims are grounds for permanent disqualification and reporting to appropriate authorities.

1Owner information

Owner full legal name

Mailing address (reimbursement checks mail here)

Phone number

Email address

Are you the original enrolled Customer?

2Horse & enrollment

Horse name

Enrollment confirmation number

3Surgery information

Name of surgical facility

Facility address

Primary surgeon name

Date of colic incident

Date of surgery

Date of discharge

Is the surgeon licensed in the United States?

4Expense summary

Whole dollar amounts are fine. These are checked against your itemized invoice.

Total surgical facility charges ($)

Amount paid by insurance, if any ($)

Amount paid by any other third party, if any ($)

Amount you paid out of pocket ($)

5Gut X compliance verification

Was your qualifying Gut X AutoShip subscription active and uninterrupted?

Had the required daily dose been administered continuously for at least 30 consecutive days prior to surgery?

Confirm daily dose based on enrolled weight

6Documentation

After submitting this claim, email the following to Support@100XEquine.com with your confirmation number in the subject line (example: Claim CPP-123456):
• Itemized surgical invoice
• Proof of payment (receipt, canceled check, or paid invoice)
• Insurance Explanation of Benefits, if applicable
• Surgical report

Your veterinarian must also complete the Program Compliance Affidavit; the link is on the confirmation screen and in your confirmation from our team.

7Owner legal certification

All six must be checked to submit.

All information provided is true and complete. All submitted invoices reflect actual expenses paid. No reimbursement has been requested for elective procedures. I understand reimbursement is limited to $20,000 lifetime. I understand expenses reimbursed by third parties are not eligible. I understand submission does not guarantee approval.

I authorize 100X Equine to contact any listed veterinarian or surgical facility to verify information.

Digital signature (type full legal name)

Submission does not constitute approval. Claims are reviewed under the Program Terms & Conditions. Questions? Call 1-800-677-3574.

✓

Claim received.

Our program team has been notified and will follow up at .

Two things complete your claim:
1. Email your documentation to Support@100XEquine.com with your confirmation number in the subject.
2. Have your veterinarian complete the Program Compliance Affidavit within 14 days of discharge.