Dental Malpractice Quote Form

First Name

Last Name

Name of Practice

Principal Practice Address

Address Line 2

City

Zip Code

Email Address

Contact Number

Type of Practice Type of PracticeGeneral DentistryOrthodonticsOral SurgeonOthers

Years in Practice

Year Graduated Dental School

State License Number

If you are interested in additional coverage, check an option below and a representative will be in touch to discuss adding a policy. If you are interested in additional coverage, check an option below and a representative will be in touch to discuss adding a policy. Business Owners Liability Workers Compensation

What is your degree? What is your degree?DDSDMD

Do you own your practice? Do you own your practice?YesNo

Current Policy Form Current Policy FormOccurence FormClaims Made Form

Current Insurance Company

Effective Date of Policy

Liability Limits Requested Liability Limits Requested$1,000,000 / $3,000,000$1,300,000 / $3,900,000 (NY Only)$2,000,000 / $4,000,000$4,000,000 / $6,000,000$5,000,000 / $7,000,000

Have any claims been made against you in the past 10 years? Have any claims been made against you in the past 10 years? Yes No

How did you hear about us? How did you hear about us?BlogEmail InviteSearch Engine: Google, Bing, Yahoo etc.MailerSocial MediaWord of Mouth / Referral

Referrer Name