DENTAL INSURANCE APPLICATION FORM
Filled in by dentist and potential policyholder
Potential policyholder
Titel
*
Mr
Mrs
Name:
*
Firstname
Surname
ID-code:
*
Address:
*
Street, number of house/appartment
Maja/korteri number
City
Riik
Postcode
Ole hyvä ja valitse
Afghanistan
Albania
Algeria
Amerikan Samoa
Andorra
Angola
Anguilla
Antigua ja Barbuda
Argentiina
Armenia
Aruba
Australia
Itävalta
Azerbaijan
Bahama-saaret
Bahrain
Bangladesh
Barbados
Valko-Venäjä
Belgia
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia ja Hertsegovina
Botswana
Brasilia
Brunei
Bulgaria
Burkina Faso
Burundi
Kambotsa
Kamerun
Kanada
Kap Verde
Caymansaaret
Keski-Afrikan tasavalta
Chad
Chile
Kiina
Joulusaaret
Kookossaaret (Keeling)
Kolumbia
Komorit
Kongo
Cookinsaaret
Costa Rica
Cote d'Ivoire
Kroatia
Kuuba
Curaçao
Kypros
Tsekin tasavalta
Kongon tasavalta
Tanska
Djibouti
Dominica
Dominikaaninen tasavalta
Ecuador
Egypt
El Salvador
Päiväntasaajan Guinea
Eritrea
Viro
Etiopia
Falklandinsaaret
Fär-saaret
Fiji
Suomi
Ranska
Ranskan Polynesia
Gabon
Gambia
Georgia
Saksa
Ghana
Gibraltar
Kreikka
Grönlanti
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Honk Kong
Unkari
Islanti
Intia
Indonesia
Iran
Irak
Irlanti
Israel
Italia
Jamaika
Japani
Jersey
Jordania
Kazakstan
Kenia
Kiribati
Pohjois-Korea
Etelä-Korea
Kosovo
Kuwait
Kirgisia
Laos
Latvia
Libanon
Lesotho
Liberia
Libya
Liechtenstein
Liettua
Luxemburg
Macao
Makedonia
Madagaskar
Malawi
Malesia
Malediivit
Mali
Malta
Marshallinsaaret
Martinique
Mauritania
Mauritius
Mayotte
Meksiko
Mikronesia
Moldova
Monako
Mongolia
Montenegro
Montserrat
Marokko
Mosambik
Myanmar
Vuoristo-Karabah
Namibia
Nauru
Nepali
Alankomaat
Alankomaiden Antillit
Uusi-Kaledonia
Uusi-Seelanti
Nicaragua
Niger
Nigeria
Niue
Norfolkin saari
Pohjois-Kyproksen turkkilainen tasavalta
Northern Mariana
Norja
Oman
Pakistan
Palau
Palestiina
Panama
Papua-Uusi-Guinea
Paraguay
Peru
Filippiinit
Pitcairnin saaret
Puola
Portugali
Puerto Rico
Qatar
Kongon tasavalta
Romania
Venäjä
Ruanda
Saint Barthelemy
Saint Helena
Saint Kitts ja Nevis
Saint Lucia
Saint Martin
Saint Pierre ja Miquelon
Saint Vincent ja Grenadiinit
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seysellit
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon-saaret
Somalia
Somalimaa
Etelä-Afrikka
Etelä-Ossetia
South Sudan
Espanja
Sri Lanka
Sudan
Suriname
Huippuvuoret
eSwatini
Ruotsi
Sveitsi
Syyria
Taiwan
Tadžikistani
Tansania
Thaimaa
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad ja Tobago
Tristan da Cunha
Tunisia
Turkki
Turkmenistan
Turks-ja Caicossaaret
Tuvalu
Uganda
Ukraina
Yhdistyneet arabiemiirikunnat
Iso-Britannia
Yhdysvallat
Uruguay
Uzbekistan
Vanuatu
Vatikaani
Venezuela
Vietnam
Brittiläiset Neitsytsaaret
Mansaari
Yhdysvaltain Neitsytsaaret
Wallis ja Futuna
Länsi-Sahara
Jemen
Sambia
Zimbabwe
Muu
State
E-mail address:
*
example@example.ee
Phone number:
*
Insurance benefit package
NB! Please choose only 1 preferred benefit package and 1 payment method
Package BRONZE
12.40 € per month
133.60 € per year
Package SILVER
19.80 € per month
213.80 € per year
Package GOLD
30.75 € per month
332.10 € per year
Dentist declaration
If potential policyholder has any pre-existing condition below please insert number of tooth according to FDI numbering (see tooth chart below) into the box or boxes below:
Status of the teeth:
Tooth number
Tooth number
Tooth number
Tooth number
Tooth number
Tooth number
Tooth number
Tooth number
Missing tooth (incl.wisdoms)
Periodontal pockets greater than 3mm
Existing crowns (also mark teeth spaces that are bridged)
Decayed teeth (only dentin and pulp decay)
Dentist name:
*
Contracted Practice name:
*
Contracted Practice Reg.no:
*
Date:
*
-
Month
-
Day
Year
Date
Transaction type
New
Renewal
Cancellation
Amendment
My Products
prev
next
( X )
annual
$
122.00
monthly
$
12.00
Yhteensä
$
0.00
Credit Card
First Name
Last Name
Credit Card Number
Security Code
January
February
March
April
May
June
July
August
September
October
November
December
Expiration Month
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
Expiration Year
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Ole hyvä ja valitse
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Muu
Country
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