This Application Form, which is designed for practitioners on the Dental Council Register, must be signed by the Applicant. It is the duty
of the Applicant to disclose all material facts. For the purpose of this Application Form, a material fact shall be deemed to be one
that would be likely to influence the judgement of a prudent insurer in fixing the premium or determining whether to underwrite the
risk. Each section of this Application Form must be completed in full. Incomplete forms will not be accepted. Should there be insufficient
room on any part of the Application Form to record all necessary details, please use the space provided in Section 5 with reference
to the appropriate question.
Failure to disclose full and accurate details may entitle Insurers to void your contract of insurance and will mean that you are not entitled
to any benefits of, nor make any claims against, your policy. It is the responsibility of the Applicant to notify any future change
of address or any changes in their professional circumstances.
€1,000,000 Any One Claim and €2,000,000 in the Annual Aggregate
These limits of indemnity operate in cognisance of the HSE medical card scheme limit requirements.
The excess on this policy is €0 (NIL) each and every claim
Should you have any questions, please contact Challenge Insurance Brokers Limited on +353 1 8395942.
THE SUBMITTING OF THIS APPLICATION FORM DOES NOT BIND THE APPLICANT, OR INSURERS, TO COMPLETE A CONTRACT OF INSURANCE.