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Home > Malpractice > Dental Profesional Liability Application
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Dental Profesional Liability Application


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

  • Please Tell Us About Yourself
  • Please Tell Us About Your Requested Professional Liability Insurance Coverage
  • Please Tell Us About Your Practice
  • Please Tell Us about Your Specialty and Procedures
  • Please Tell Us About Your License and Experience
  • Please Tell Us About Your Claims History
  • Additional Remarks
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?

How did you hear about L Squared?
Requested Effective Date *
Requested Type of Coverage

Requested Limits






Practice Affiliation


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?

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) *
Indicate your Practice Specialty (Please check all that apply)















Indicate which of the following procedures you perform (Select at least one)






Under which of the following types of sedation/anesthesia do you treat patients (Select at least one)


Do you administer sedation/anesthesia to patients other than your own?

Do you administer General Anesthesia/Deep Sedation?

Have you ever had your license to practice dentistry denied, revoked, suspended, placed on probation, subject to reprimand, voluntarily surrendered, limited in any manner or is it currently under investigation:

Have you ever had your DEA or State permit to dispense or prescribe drugs denied, revoked, suspended, placed on probation, subject to reprimand, voluntarily surrendered, limited in any manner or is it currently under investigation:

Have you ever had your privileges with a hospital, managed care organizations or other healthcare denied, revoked, suspended, placed on probation, subject to reprimand, voluntarily surrendered, limited in any manner or is it currently under investigation

Have you ever had any professional liability insurance cancelled, declined, refused, or non-renewed?

Have you ever been charged with or convicted of a felony or misdemeanor (other than a minor traffic violation)?

Are you or have you ever been evaluated for, diagnosed with, treated for, or hospitalized for: alcohol, narcotics, any other substance abuse (or central nervous system stimulants or depressants), sexual addiction, mental or emotional illness?

Have you become aware of any chronic illness or physical defect that impairs or could impair your ability to practice your specialty?

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?

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?

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

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?

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.
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2430 Camelot Ct SE
Grand Rapids, MI 49546

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