BCDA - Dentists Claim Form

BCDA - Dentists Claim Form
Name:*

First NameLast Name
Member Number:*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Please indicate which section of coverage you are claiming under: Please note that not all sections of cover are included in every policy. Sections 1.11 and 1.21 is for those who purchased the premium coverage. *
Section C: Details of Claim
Name of other party involved:*

First NameLast Name
Address of other party Involved:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What was the date of the incident:*

MonthDayYear
Date
What date did you first become aware of possible legal action?*

MonthDayYear
Date
Please provide full details of the circumstances giving rise to the claim which should be in the form of a chronology of events. Attach a separate document if necessary. Please attach relevant documentation in support of your claim. If the claim relates to a College Complaint please attach your draft response which will be reviewed by the lawyer that is appointed to represent you*
Supporting Documents
You may upload up to five supporting documents. Individual file size should not exceed 3MB. Accepted file types: .doc, .docx, .jpg, .pdf, .png You can only upload 8 documents.

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Declaration of Bona Fides
I SOLEMNLY DECLARE that I am the claimant for legal expense insurance and by submitting the fully completed Claim Form, all of the statements and particulars set out in this Claim are true and factual to the best of my knowledge, information and belief. I have made full and frank disclosure of all material facts relating to the matter to which this Claim relates. These statements which are made by me shall be of the same force and effect as if given by me under oath or affirmation.*

YESNO
Notice Concerning Personal Information
By completing and submitting this claim form to STERLON you have provided us with your consent to the collection, use and disclosure of your personal information, including that previously collected, for the purposes of: communicating with you; evaluating claims; detecting and preventing fraud; analyzing business results; and acting as required or authorized by law. We may also use your personal information to tell you about, offer or provide other services or products.*

YESNO
Should be Empty:

BCDA - Dentists Claim Form

Section C: Details of Claim

Supporting Documents

Declaration of Bona Fides

Notice Concerning Personal Information