Dental Warranty Claim Form

Part A – Details of injured person (Claimant)

Part B – To be completed by Parent/Guardian

if injured person is under 18 years.

Part C – Details of Dental Injury

Part D – Mouthguard Details

Part E – Must be uploaded as PDF or JPEG with this claim.

1. Written statement from a licenced dentist providing necessary dental treatment (dated within 14 days of the injury, loss, accident and/or damage).

2. Written statement from (i) game official, if the injury, loss, accident and/or damage occurred during a supervised contest or (ii) coach, if the injury, loss, accident and/or damage occurred during a supervised training session, as the case may be, that the mouthguard was being properly used at the time the injury, loss, accident and/or damage occurred.

3. The receipt or invoice from the retailer for the purchase of the mouthguard worn at the time the injury, loss, accident and/or damage occurred.

Part F – To be mailed to Warranty Department, Signature Mouthguards Pty Ltd at PO Box 2099 Hornsby Westfield NSW 1635 Australia, before a claim can be paid.

The mouthguard used at the time the injury, loss, accident and/or damage occurred (becomes the sole and exclusive property of Signature Mouthguards Pty Ltd).

Part G – To be uploaded or mailed to Warranty Department, Signature Mouthguards Pty Ltd at PO Box 2099 Hornsby Westfield NSW 1635 Australia, before a claim can be paid.

Details of a school/club or other accident insurance policy under which the injured player was covered and details of a claim made under such policy for the injury, loss, accident and/or damage detailed in this claim and details of any amounts received or receivable.

Details of any claim made on a personal health fund and details of any refund received or receivable.

Photo images taken of the damaged tooth/teeth prior to the commencement of dental treatment and on completion of the dental treatment (if applicable).

Declaration

I declare that the information within this Claim Form and the attachments is true and correct.  I hereby authorise the dental professional who has/is providing treatment for my injury to provide any information required to assist in processing this claim. I understand that Signature Mouthguards Pty Ltd may appoint its own dental professional to assist in the examination of this information, and I agree to attend an oral examination by that dental professional if required.