Mikel's Insurance Services - Dentists Professional Liability Insurance

Dentists Professional Liability Insurance

Free Premium Estimate Questionnaire (Non-Binding) Indication of Coverage

Click here for a PDF version.

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

Part 1

Part 2

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 3^rd molars

		extract partially impacted 3^rd molars

		Extract Fully Impacted 3^rd 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

© 2012 Mikel’s Insurance Services, 7847 Florence Ave., Suite 120 Downey, CA 90240