Mikel's Insurance Services
7847 Florence Avenue, Suite #120
Downey, CA 90240


Fax: 562-928-8149

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

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
(C) Please check all boxes that apply if you
(D) Do you practice full-time or part-time
(E) Please check all boxes that apply. I am an
(F) Have you had any professional liability claims within the past 8 years?

Part 4

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

Part 5

My current policy is (check one)

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