Application

General Information

Name Practice Name Address County Best Time to Contact You Next Step

Practice Information

Dental Specialty Number of hours worked per week Do you Administer Do you Perform Do you provide elective facial cosmetic procedures, Botox, collagen injections, or other dermal fillers for cosmetic purposes in your practice? Select Yes No Previous Step Next Step

Desired Type of Coverage

Select Claims-Made Occurrence (where available) If "Claims Made" - Retroactive Date

Desired Level of Coverage

Primary Coverage Limits Excess Coverage Limits (where available)

Current Policy

Previous Step Next Step

Education

Any professional liability claims or board or license action in the last 10 years?
(If yes, a loss run and additional information may be required.) Select Yes No Current membership(s) Is your practice a parternship, corporate, or LLC? Select Yes No If Yes what is the name? Number of Dentists

This information is for a premium indication only. A fully completed submission, including an application, is required for a coverage determination.

Previous Step