Get a Quote: Dentists - Professional Services Plan

Full Name*

Primary Practice Name*

Primary Practice Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Work City & State*

Work County & Zip Code*

Work Phone*

Work Email*

I am filling out this estimate form to get a quote on the following coverages*

Professional Liability Only
Professional Liability and General Liability
Professional Liability, General Liability, Property Coverage
Property Coverage
Workers Compensation

I am filling out this form to receive a premium indication on the following coverages and I understand that additional information is required to quote*

Builders Risk Coverage
Cyber Liability Insurance
Employment Practices Liability (EPLI)
ERISA Coverage
Flood Coverage
Umbrella Coverage
Wind Coverage
None

Professional Liability Insurance History

Please answer the following.

Current Carrier*

Name of your current insurance carrier

Current Limits*

Graduation Date*

Years in Practice*

Current Effective Date*

Date of your current effective insurance date

Type of Policy*

Number of Hours Practiced Per Week*

Have you had any professional Liability Claims of Board Complaints*

About Your Practice

Do you treat patients under conscious sedation?*

Question to find out if you treat your patient under conscious sedation

Do you treat patients under conscious sedation only in a hospital?*

Question to find out if and where you treat your patient under conscious sedation

Do you treat patients under conscious sedation only in a hospital?*

Question to find out if and where you treat your patient under conscious sedation

Do you treat patients under conscious sedation only in a hospital?*

Question to find out if and where you treat your patient under conscious sedation

Do you treat patients under deep sedation/general anesthesia?*

Question to find out if you treat your patient under deep sedation

Do you treat patients under deep sedation/general anesthesia only in a hospital?*

Question to find out if and where you treat your patient under deep sedation

Do you treat patients under deep sedation/general anesthesia only in a hospital?*

Question to find out if and where you treat your patient under deep sedation

Do you treat patients under deep sedation/general anesthesia only in a hospital?*

Question to find out if and where you treat your patient under deep sedation

Are you an oral surgeon?*

Question to find out if you are an oral surgeon

Which of the following procedures are performed by you or by someone under your supervision/direction?*

implant surgery
extraction of impacted teeth
implant restoration
molar endodontics on permanent teeth
none of these

Question to find out if you treat your patients with certain conditions

Practice Income Interruption (i) ($)

Valued practice income protection pays you the daily income you would lose from a covered loss; with no requirement that you document your losses or that you reschedule patients.

How much money would you need to receive for each day you can't practice? ($)*

Worth of your services if you are unable to work.

Blanket Practice Property Protection (i)

If tomorrow you had to replace everything-operatories, tools, office equipment, x-rays, patient charts, records, furniture, décor, the personal property in the office and your accounts receivable that became uncollectible

How much money would you need? ($)*

Value of your property and assets

When does your coverage expire?*

What is your building's construction? ($)*

Building Coverage

Please answer the following.

If you own your own building, would you like to include it in your quote for a complete package policy?*

Building Value ($)*

If you own your property, the value of the building

Year Built*

If you own your property, the year the building was built

Square Footage*

If you own your property, the size of your building in square foot

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INSURANCE ESTIMATE FOR DENTISTS

Please answer the following. We will provide a quote estimate and details of the coverage to your preferred contact method.

Professional Liability Insurance History

About Your Practice

Practice Income Interruption (i) ($)

Blanket Practice Property Protection (i)

Building Coverage