Dentist Professional Liability Insurance

Primary Phone Number *

(A) I am a General Dentist or Specialist

General Dentist
Specialist

If Specialist, please state Specialty

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

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

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?

If Yes, please provide details, status and amounts paid

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

My current Professional Liability Insurer is

Expiration Date (Month / Day / Year)

My current policy is (check one)

"Claims-Made"
Occurrence

If "Claims-Made" was selected, Retro date of (Month / Day / Year)

Submission Validation

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.

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