Prior Acts Professional Liability Insurance Coverage for Retired Dentists or Dentists Previously Registered in Alberta

Are you currently an active member with the CDSA? *

Yes

No

Date of Retirement/Non-Practicing Date: * +

Please complete this application in full, since it forms the basis upon which insurance is provided. In the event of a non-disclosure and/or misrepresentation, the policy may be voided at the option of the Insurer.

Current year of Coverage: *

Primary Contact Details

First Name *

Last Name *

Do you have a Professional Corporation to add? *

Yes

No

Please provide your Corporation name: *

Practice Permit Number: *

Email Address
Note: Please advise us immediately if your email address changes; otherwise you may not receive critical renewal correspondence *

Re-enter your email address *

Mailing Street Address *

Mailing Address City *

Province * 🛈

State or Region *

Country *

Mailing Address Postal or ZIP Code *