THE DENTIST'S ADVANTAGE

QUICK QUOTE REQUEST FORM

PLEASE COMPLETE AND RETURN BY MAIL OR FAX FOR AN ESTIMATED PREMIUM QUOTATION FOR YOU AND YOUR PRACTICE.  IF YOU HAVE ANY QUESTIONS, PLEASE CALL

Your Name                                                                                                                                        

Practice Name    

                            SOLE PROPRIETOR   PARTNERSHIP    PA or PC   LLC 

Address             

Address             

City                         STATE              ZIP         

E-Mail     Web Site  

Telephone Number      Fax Number  

Professional Liability

Limits of Liability

$1,000,000/$3,000,000

$2,000,000/$6,000,000

$3,000,000/$6,000,000

$4,000,000/$6,000,000

$5,000,000/$6,000,000

Type of Coverage  Claims-Made or Occurrence  Claims Made Occurrence

If claims-made please specify your Retroactive Date (Also known as Prior Acts Date)

Do you have coverage in effect now?  Yes No   If yes, how many years have you been insured? 

                                                                 Name of Current Insuror 

                                                                Current Premium 

When did you graduate from dental school?   

When did you graduate from residency program? 

If you have attended a Risk Management Program in the last 3 years, please provide the name of the program and the date of attendance.

                Program Name   Program Date 

Have you had any professional liability claims?   No Yes  

    If, yes please provide the date of the claim(s) and amount paid.

Practice Property and Liability

What would it cost to replace the contents of your office, including operatory equipment, furniture, fixtures, records, supplies, improvements and betterments?  

How many operatories? 

If you own the building and want to include Building Owners Coverage, please provide the value for the building.             

Is your practice located in a condominium unit that you own?  No Yes

What is the construction of the building where your practice is located?

    Wood Frame Brick or Concrete Block with Wood Floors and or Ceiling Brick, concrete or concrete block walls with concrete or metal floor joists ceilings Fire Resistive construction with all metal and or concrete walls, floors and ceilings

Does the building have a sprinkler?   Yes No

Do you occupy at least 75% of the building?  Yes No

How do you want to receive the proposal?  Mail Fax E-Mail