| Company Information |
| Company Name
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| First Name
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| Last Name
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| Street
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| City
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| State
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| ZIP / Postal Code
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| Primary Phone Number
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| Fax Number
Optional
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| E-Mail Address
Required
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| Best time to contact
Optional
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| How would you like to receive your quote?
Optional
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| A. AVAILABLE PREMIUM CREDITS |
| Check (4) all that apply
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| Organizations
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| B. PROFESSIONAL LIABILITY COVERAGE |
| I am currently Insured
Required
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| If claims-made, what is your retroactive date?
Required
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| Please quote
Required
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| DENTAL PROFESSIONAL LIABILITY LIMITS - Please check desired limit option
Optional
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| Requested effective date
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| Are you a General Dentist?
Required
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| If limiting your practice to a specialty, are you licensed in that specialty?
Required
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| Level of Sedation Used
Required
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| What is your specialty?
Optional
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| Please provide the percentages (based on number of procedures) of your practice which fall into the following CDT codes (must total 100%) |
| Diagnostic - D0100 - D0999
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| Preventive - D1000 - D1999
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| Restorative - D2000 - D2999
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| Endodontics - D3000 - D3999
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| Periodontics - D4000 - D4999
Optional
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| Prosthodontics (Removable) - D5000 - 5899
Optional
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| Maxillofacial Prosthetics - D5900 -D5999
Optional
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| Implant Services - D6000 -D6199
Optional
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| Prosthodontics (Fixed) - D6200 -D6999
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| Oral and Maxillofacial Surgery - D7000 - D7999
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| Orthodontics - D8000 -D8999
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| Adjunctive General Services - D9000 -D9999
Optional
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| Do you perform any surgical procedures?
Required
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| If "yes," please estimate the percentage each surgical procedure bears to your total practice (based on numbers of procedures) on an annual basis. |
| Surgical Implants
Optional
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| Extractions of bony impacted, or partially bony impacted teeth
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| Other dental cosmetic procedures (excluding biopsies, but including T MJ)
Optional
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| Other surgery, including non-dental procedures (describe)
Optional
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| I administer the following types of Anesthesia. (Please check all that apply)
Optional
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| Have you ever had any disciplinary action, restriction, suspension, probation or revocation of a license to practice dentistry?
Required
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| Other than traffic violations, have you ever been convicted of a crime?
Required
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| Have you ever been declined or cancelled for any Dental Professional Liability Insurance? (Missouri residents: Do not respond)
Optional
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| In the past 10 years, have you been involved, directly or indirectly, in a claim or suit arising out of the rendering or failure to render professional services?
Required
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| If Yes, how many (Open and Closed)
Optional
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Submission Validation Required |
Enter the Validation Code from above.
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