Dentist Professional Liability Insurance
Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.
Free Premium Estimate Questionnaire (Non-Binding) Indication of Coverage 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.
If Yes, please provide details, status and amounts paid
Part 4
Please check Per Claim / Aggregate limits in which you are interested
Part 5
Quotations and coverage may be issued only upon acceptance of a fully completed Medical Protective Company application
Important NoticeAny
submissions or payments made via this website do not constitute a
binding agreement to your policy or coverages. Changes and
payments to policies are not effective or binding until you, or any
party involved, receive official notice from either your insurance agent,
or your insurance company. If you have any questions, please feel free to
contact us. Per the terms of our
online privacy policy we will not resell your information to any third-party.
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