Dentists Professional Liability Insurance

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

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

Part 1

First Name

Last Name

Practice Name

Number of Dentists

Practice Address

Practice City

Practice State

Practice Zip Code

Phone Number

Fax

Email Address

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 General Dentist Specialist

If Specialist, please state Specialty

(B) Date I started practicing dentistry (month / year)

(C) 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 Perform Botox or Dermal Fillers None of the Above

(D) Do you practice full-time or part-time Full-Time Part-Time

Average Hours per Week

(E) Please check all boxes that apply. I am an Employee Independent Contractor Owner

(F) Have you had any professional liability claims within the past 8 years? Yes No

If Yes, please provide details, status and amounts paid

Part 4

Please check Per Claim / Aggregate limits in which you are interested $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