Dental Profesional Liability Application

First Name *

Last Name *

Date of Birth *

National Provider Identifier (NPI) Number *

Dental License #(s) *

Street *

City *

State *

ZIP / Postal Code *

Office Number

Cell Number

E-Mail Address *

Website Address

Have you ever failed any portion of the Dental Board Exam more than three times?

Yes
No

How did you hear about L Squared?

Requested Effective Date *

Requested Type of Coverage

Claims Made
Occurrence

Requested Limits

$100,000/$300,000
$200,000/$600,000
$250,000/$750,000
$400,000/$1,200,000
$500,000/$1,500,000
$1,000,000/$3,000,000
Other

Practice Affiliation

Owner
Employee
Independent Contractor

Please provide the number of Allied Health Personnel working in your office *

Do you practice on behalf of a dental corporation, partnership, or other entity?

Yes
No

If yes, please provide the legal name of entity, and any DBA names

Please enter all practice addresses *

Please indicate your average number of practice hours per week that will be covered by this policy including office hours, administrative activities, direct patient care, surgery, consultation, etc. (excluding on-call) *

Are you currently involved in or have you ever been involved in a malpractice claim or suit including any expression of intent by a third party (i.e. records request, incident reports, or notices of intent) even if a suit was never filed?

Yes
No

Do you know of or is it reasonably foreseeable from the facts or circumstances regarding any procedure, treatment or diagnosis you have performed or made in the past that might reasonably lead to a claim or suit being brought against you?

Yes
No

Are there outstanding incidents, claims or suits, or potential incidents, claims or suits, regardless of merit, pending against you?

Yes
No

Have you been notified to respond to, appear before or been investigated by any regulatory agency and/or state dental board on a complaint of any nature?

Yes
No

Please use the space below to provide any further explanation to any of the previous responses. Please also include any additional information or attach documentation as needed to best inform PracticeProtection of anything that would be useful in the unde

Submission Validation

Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.