indi statement of fact

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Name *

Address

Email *

Contact Tel. No

1. I am an appropriately qualified registrant of CORU and a fully paid-up member of the Irish Nutrition and Dietetic Institute *

YES NO

1. I am an appropriately qualified registrant of CORU and a fully paid-up member of the Irish Institute of Radiography and Radiation Therapy *

YES NO

2. Are you aware of any injury to, or death, disease or illness of any patient, or any other circumstances which may give rise to a claim against you, as an individual, or which has resulted in a claim being made against you, as an individual, in the last five years? *

YES NO

3. Have you had any proposal for Professional Liability Insurance made on behalf of your business declined, cancelled, refused renewal or had special terms imposed? *

YES NO

4. Have you or any of your business partners or Directors ever been convicted of, or charged with, a criminal offence other than a motoring offence? *

YES NO

5. Have you ever been fined or served imprisonment or been issued with a prohibition notice under statutory legislation? *

YES NO

Confirmation *

YES NO

AIG Europe S.A. is authorised by the Luxembourg Ministère des Finances and supervised by the Commissariat aux Assurances, and is regulated by the Central Bank of Ireland for conduct of business rules.

STATEMENT OF FACT

Members Of The Irish Nutrition And Dietetic Institute

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First Name	Last Name
Phone Number *	Email