First Name:*
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Last Name:*
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Phone Number:*
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- Ext. |
Email:*
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I would prefer my quote by:*
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Year Graduated:*
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Year Licensed:*
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Practice Address:*
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Do you currently have malpractice
insurance?*
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Current Insurance Company:
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Expiration Date of Current Policy:
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Are you presently insured in a claims-made
program?*
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Retroactive Date:
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Type of quotation you are requesting:
| Note: You may request
quotations for one or more programs as well as various coverage limits. |
Program Desired:*
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Limits Desired:*
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How many hours a week are you
actually involved in the practice of dentistry?*
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Do you perform the surgical
removal of wisdom teeth?*
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If Yes to above please check
all that apply:
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Does your practice include the
surgical placement of implants? *
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Do you provide any cosmetic
facial services including Botox injections, liposuction, or face lifts?*
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Do you provide Sleep Dentistry
services?*
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Have you been involved in any
claim, suit or incident which may give rise to a claim within the past 10
years?*
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Are you a faculty member of an
accredited university dental school?*
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If yes to above, are you
covered at the school while you practice there?
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Is this your first malpractice
policy since graduating from dental school?*
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Have you completed a Risk
Management course within the past 12 months?*
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I would also be interested in
quotes for?*
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Additional information that may
help with your dental malpractice insurance quote:
Please include details of past claim(s) here.
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Please click the Submit button once. Thank you. |
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electronic submission. |