Dentist Professional Liability Call Us 855-758-9649

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

First Name *

Last Name *

ZIP / Postal Code *

Primary Phone Number *

E-Mail 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.

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

Average Hours per Week

(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

$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 (Month / Day / Year)

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

Submission Validation

Required

Important Notice
Any 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.

Insurance Websites Designed and Hosted by Insurance Website Builder