BCDA - Dentists Claim Form
Name:
*
First Name
Last Name
Member Number:
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
Please enter a valid phone number.
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.
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Please Select
1.2 Fitness to Practice and Licensing
1.3 Professional Misconduct
1.4 Billing Practice Complaints
1.5 Billing Profile Investigation
1.6 Branch of Contractual Right to Practice
1.7 Coroner's Investigation & Inquests
1.8 Personal Injury
1.9 Legislated Investigations
1.10 Human Rights Investigation
1.11 Criminal Defense
1.12 Employment Disputes
1.13 Contract Disputes and Debt Recovery
1.14 Property Disputes
1.15 Tax Disputes
1.16 Privacy Legislation Protection
1.17 Anti-Spam Legislation Protection
1.18 Appeals
1.19 Legal Document Review
1.20 Letter Writing Service
1.21 Human Resources Assistance
Section C: Details of Claim
Name of other party involved:
*
First Name
Last Name
Address of other party Involved:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What was the date of the incident:
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-
Month
-
Day
Year
Date
What date did you first become aware of possible legal action?
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-
Month
-
Day
Year
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
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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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of
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.
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YES
NO
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.
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YES
NO
Submit
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