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Dentists Professional Liability Insurance
Free Premium Estimate Questionnaire (Non-Binding) Indication of Coverage

Download PDF Click here for a PDF version.

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

Part 1
Your Name: *
Practice Name: *
No. of Dentists:
Practice Address: *
Practice City: *
Practice State: *
Practice Zip Code: *
Telephone: *
Cellphone:
Fax:
Email: *

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
If Specialist, please state Specialty:
(B) Date I started practicing dentistry:
/
(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
(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 or incidents 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

Part 5
My current Professional Liability Insurer is: *
Expiration Date: / / *
Premium:
My current policy is (check one): *
"Claims-Made" with Retro date of:
/ /
Occurrence


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

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