BC Dental Association Claim Form

If you require assistance in completing this form please contact the STERLON Claims Department at 1-888-STERLON (783-7566).

STERLON may require completion of a further form by a lawyer before your claim can be fully considered, the cost of which will be paid by Underwriters.

Section A: Details of Insured
Name of Insured*
Policy Number*
Evidence or Certificate Number*
Contact Name*
Street Address*
City*
Province*
Postal Code*
Phone*
Email*
Section B: Sections of Coverage
Please indicate which section of coverage you are claiming under*
Please note that not all sections of cover are included in every policy.
Please Note:
If your area of coverage is not shown it is likely that the issue for which you are seeking assistance is not available under this policy of insurance. Please call 1-888-STERLON (783-7566) and speak with a loss adjuster in the claims department for further assistance.
Section C: Details of Claim
Name of other party involved*
What was the date of the incident?*
DD slash MM slash YYYY
What date did you first become aware of possible legal action?*
DD slash MM slash YYYY
Please provide full details of the circumstances giving rise to the claim. Attach separate document if necessary giving a chronology of events and/or any other relevant documentation in support of your claim.*
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
Drop files here or
Accepted file types: jpg, png, doc, docx, pdf, jpeg, Max. file size: 5 MB, Max. files: 8.
Declaration of Bona Fides
Declaration*
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.
I agree.
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.
I agree.
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BC Dental Association Claim Form

Section A: Details of Insured

Section B: Sections of Coverage

Please Note:

Section C: Details of Claim

Declaration of Bona Fides