Dental Malpractice Quick Quote Form

CONTACT INFORMATION

First Name (required)

Your Last Name (required)

PRIMARY PRACTICE LOCATION

Name

Address (required)

City (required)

State (required)

Zip (required)

Phone(required)

Your Email (required)

How did you hear about us, who should we thank? (required)

MAILING ADDRESS (if other than practice location)

Address

City

State

Zip

COVERAGE INFORMATION (all fields are required)

1. Do you currently have professional liability insurance coverage?*
 Yes No

1b. If so, what type of policy do you have?*
 Claims-made Occurrence Both

1c. If claims made, please provide the retroactive date:

2. What type of coverage are you interested in?*
 Claims-made Occurrence Both

3. Do you have an ownership interest in your practice?*
 Yes No

4. Choose which level(s) of coverage you would like to be quoted for (per claim/aggregate):*
 $1,000,000/$3,000,000 $2,000,000/$4,000,000 $2,000,000/$6,000,000 $3,000,000/$6,000,000 $4,000,000/$6,000,000 $5,000,000/$6,000,000

5. Would you like your premium estimate to include General Liability Coverage?*
 Yes No
If selected, your quote will also include coverage for Billing Errors & Omissions ($2,500 annual aggregate limit) and Employment-related Practices Liability ($5,000 annual aggregate limit). (Higher limits may be available.)

6. What date would you like your policy to become effective?*

7. Do you own a corporation?*
 Yes No

8. Do you have any independent contractors?*
 Yes No

If yes, how many independent contractors do you have?*

TELL US ABOUT YOUR EXPERIENCE (All fields are required)

1. I am a new practitioner (newly licensed within the past 3 years)*
 Yes No

2. I graduated from dental school in (required)

3. I completed my residency program in (required)

4. What is the effective date (month/year) of your first Malpractice Insurance policy? (required)

5. I am part-time, practicing fewer than 20 hours per week*
 Yes No

6.If so, what is your average practice hours per week?*

7. I have been claims-free for the past five (5) years*
 Yes No

8. I am a faculty member at an accredited dental school*
 Yes No

a. If yes, please indicate the number of hours spent teaching per week*

9. I am a member of the Academy of General Dentistry (AGD)*
 Yes No

If yes, please indicate level of membership*
 Member (AGD) Fellow (FAGD) Master (MAGD)

10. I am a member of the American Dental Association
 Yes No

11. I am a member of the National Dental Association*
 Yes No

12. I am a member of other dental associations*
 Yes No

a. If yes, please indicate association*

Tell us about your practice (All fields required)

1. What is your dental specialty?*
 General Dentist Endodontist Oral Pathologist Oral Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist Other

a. If other, please indicate

2. Do you place Surgical Implants?*
 Yes No

3. Do you perform Extractions of bony impacted, or partially bony impacted teeth?*
 Yes No

4. I administer the following types of anesthesia (check all that apply):*
 IV conscious sedation IM conscious sedation Sub-cutaneous conscious sedation General anesthesia None

5. What percentage of your clientele are PEDIATRIC patients that are paying through MEDICAID?*