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.
Date of Birth *
If yes, please provide the legal name of entity, and any DBA names
Please enter all practice addresses *
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
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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
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