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1. Do you currently have professional liability insurance coverage?* Yes No
1b. If so, what type of policy do you have?* Claims-made Occurrence Both
1c. If claims made, please provide the retroactive date:
2. What type of coverage are you interested in?* Claims-made Occurrence Both
3. Do you have an ownership interest in your practice?* Yes No
4. Choose which level(s) of coverage you would like to be quoted for (per claim/aggregate):* $1,000,000/$3,000,000 $2,000,000/$4,000,000 $2,000,000/$6,000,000 $3,000,000/$6,000,000 $4,000,000/$6,000,000 $5,000,000/$6,000,000
5. Would you like your premium estimate to include General Liability Coverage?* Yes NoIf selected, your quote will also include coverage for Billing Errors & Omissions ($2,500 annual aggregate limit) and Employment-related Practices Liability ($5,000 annual aggregate limit). (Higher limits may be available.)
6. What date would you like your policy to become effective?*
7. Do you own a corporation?* Yes No
8. Do you have any independent contractors?* Yes No
If yes, how many independent contractors do you have?*
1. I am a new practitioner (newly licensed within the past 3 years)* Yes No
2. I graduated from dental school in (required)
3. I completed my residency program in (required)
4. What is the effective date (month/year) of your first Malpractice Insurance policy? (required)
5. I am part-time, practicing fewer than 20 hours per week* Yes No
6.If so, what is your average practice hours per week?*
7. I have been claims-free for the past five (5) years* Yes No
8. I am a faculty member at an accredited dental school* Yes No
a. If yes, please indicate the number of hours spent teaching per week*
9. I am a member of the Academy of General Dentistry (AGD)* Yes No
If yes, please indicate level of membership* Member (AGD) Fellow (FAGD) Master (MAGD)
10. I am a member of the American Dental Association Yes No
11. I am a member of the National Dental Association* Yes No
12. I am a member of other dental associations* Yes No
a. If yes, please indicate association*
1. What is your dental specialty?* General Dentist Endodontist Oral Pathologist Oral Radiologist Oral Surgeon Orthodontist Pediatric Dentist Periodontist Prosthodontist Public Health Dentist Other
a. If other, please indicate
2. Do you place Surgical Implants?* Yes No
3. Do you perform Extractions of bony impacted, or partially bony impacted teeth?* Yes No
4. I administer the following types of anesthesia (check all that apply):* IV conscious sedation IM conscious sedation Sub-cutaneous conscious sedation General anesthesia None
5. What percentage of your clientele are PEDIATRIC patients that are paying through MEDICAID?*