Dental Malpractice Insurance Quote

Company Information

Company Name *

First Name *

Last Name *

Street *

City *

State *

ZIP / Postal Code *

Primary Phone Number *

Fax Number

E-Mail Address *

Best time to contact

How would you like to receive your quote?

Email
Fax
Phone

A. AVAILABLE PREMIUM CREDITS

Check (4) all that apply

I graduated from dental school I am a new practitioner (within last 3 years)
I am part-time, less than 20 hours per weekI have been claims-free for the past 5 years
I am in a group practiceI am a staff member at an accredited dental school
I am a member of the Academy of General DentistryI am a member of the AGD Fellowship
I am a member of the AGD MastershipI am a member of the American Dental Association
I am a member of the National Dental Association I am a member of the Hispanic Dental Association
I am a member of the following organization(s)

Organizations

B. PROFESSIONAL LIABILITY COVERAGE

I am currently Insured *

Yes
No

If claims-made, what is your retroactive date? *

/

Please quote *

Claims- Made Coverage
Occurrence Coverage
Both

DENTAL PROFESSIONAL LIABILITY LIMITS - Please check desired limit option

$2,000,000/$6,000,000$3,000,000/$6,000,000
$4,000,000/$6,000,000$5,000,000/$6,000,000
$500,000/$1,500,000$1,000,000/$3,000,000
$1,300,000/$3,900,000 (NY Only)

Requested effective date *

/

Are you a General Dentist? *

Yes
No

If limiting your practice to a specialty, are you licensed in that specialty? *

Yes
No

Level of Sedation Used *

What is your specialty?

PeriodontistProsthodontist
EndodontistPediatric Dentist
Public Health DentistOral Pathologist
Oral SurgeonOrthodontist
Oral Radiologist

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

Preventive - D1000 - D1999

Restorative - D2000 - D2999

Endodontics - D3000 - D3999

Periodontics - D4000 - D4999

Prosthodontics (Removable) - D5000 - 5899

Maxillofacial Prosthetics - D5900 -D5999

Implant Services - D6000 -D6199

Prosthodontics (Fixed) - D6200 -D6999

Oral and Maxillofacial Surgery - D7000 - D7999

Orthodontics - D8000 -D8999

Adjunctive General Services - D9000 -D9999

Do you perform any surgical procedures? *

Yes
No

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

Extractions of bony impacted, or partially bony impacted teeth

Other dental cosmetic procedures (excluding biopsies, but including T MJ)

Other surgery, including non-dental procedures (describe)

I administer the following types of Anesthesia. (Please check all that apply)

I.V. Conscious Sedation
I.M. Conscious Sedation
Sub-Cutaneous Conscious Sedation
General Anesthesia

Have you ever had any disciplinary action, restriction, suspension, probation or revocation of a license to practice dentistry? *

Yes
No

Other than traffic violations, have you ever been convicted of a crime? *

Yes
No

Have you ever been declined or cancelled for any Dental Professional Liability Insurance? (Missouri residents: Do not respond)

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? *

If Yes, how many (Open and Closed)