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Dentists Professional Liability Insurance
Free Premium Estimate Questionnaire (Non-Binding) Indication of Coverage

Download PDF Click here for a PDF version.

Please answer all questions for a non-binding Premium Estimate.

Part 1
Your Name: *
Practice Name: *
No. of Dentists:
Practice Address: *
Practice City: *
Practice County: *
Practice State: *
Practice Zip Code: *
Telephone: *
Cellphone:
Fax:
Email: *

Part 2
Dental License #(s): *

Part 3
Practice Information (Please respond as completely as possible.) All sections, except section (D), are required for submission.
(A) I am a General Dentist or Specialist
If Specialist, please state Specialty:
If General Dentist, do you practice 15% or more in any area(s) of dentistry?
Yes No
If Yes, please specify area(s) and percentage(s)
(B) Date I started practicing dentistry:
/ /
(C) Do you or your employee administer IV/IM Conscious Sedation or General Anesthesia?
Yes No
(D) Please check all boxes that apply if you:
simple extracted 3rd molars
extract partially impacted 3rd molars
Extract Fully Impacted 3rd Molars
Surgical Placement of Implants
Do you use written informed consent for any of the above procedures?
Yes No
(E) Do you practice full-time or part-time?
Average Hours per Week:
(F) Please check all boxes that apply. I am an:
Employee
Independent Contractor
Owner
(G) Have any professional liability insurance policies ever been refused or canceled?
Yes No
If Yes, when and for what reason:
(H) Have you had any professional liability claims or incidents within the past 8 years?
Yes No
If Yes, please provide details, status and amounts paid:
(I) Has your license to practive dentistry or prescribe drugs ever been suspended or revoked or placed on probation?
Yes No
If Yes, please provide details:
(J) Have you completed at least three hours of risk management course(s) during the past 12 months? (Possible premium credit available.)
Yes No

Part 4
Please check Per Claim/Aggregate limits in which you are interested:
$100,000/$300,000
$200,000/$600,000
$500,000/$1,000,000
$1,000,000/$3,000,000
$2,000,000/$4,000,000
$3,000,000/$5,000,000
$4,000,000/$6,000,000
$5,000,000/$7,000,000

Part 5
My current Professional Liability Insurer is: *
Expiration Date: / / *
Premium:
My current policy is (check one): *
"Claims-Made" with Retro date of:
/ /
Occurrence


Quotations and coverage may be issued only upon acceptance of a fully completed Medical Protective Company application

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