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* indicates Required Field |
First Name:*
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Last Name:*
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Phone Number:*
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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 dental 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:
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Note: You may request quotes 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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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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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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