Dental Professional Liability Questionnaire

All Questionnaires submitted through this website are subject to carrier and underwriting review. By submitting a questionnaire through this website, there is no guarantee or warranty of coverage. Additional information may be required in order to provide a dental malpractice insurance quote.

Full Name *

Mailing Address (Street, City, Zip) *

Corporation Name or Employer Name *

Phone *

Email *

Your Practice Website

Requested Effective Date *

Select Requested Limits of Liability * ----$100,000 / $300,000$200,000 / $600,000$500,000 / $1,500,000$1,000,000 / $3,000,000$2,000,000 / $4,000,000$2,000,000 / $6,000,000$3,000,000 / $6,000,000

What is your Dental Specialty? *

When did you graduate from Dental School? (Month/Year) *

What date did you begin practicing dentistry? (Month/Year) *

How many hours per week do you practice dentistry? ----Less than 10 hours per weekBetween 10 and 20 hours per weekMore than 20 hours per week

Will you be administering Intravenous and / or Intramuscular conscious sedation? *

 Yes

 No

Will you be performing Full and/or Partial Bony Impacted Teeth Extractions * ----YesNo

Will you be performing Surgical placement of implants *

 Yes

 No

If you are a member of the AGD, are you a ----MemberFellowshipMastership

Are you a member of the:

 American Dental Association (ADA)

 National Dental Association (NDA)

 Hispanic Dental Association (HDA)

Do you currently have a professional liability policy in force? *

 Yes

 No

If claims-made, what is the retroactive date?

I would like to receive a quote for a/an: *

 Claims-Made policy with retroactive coverage

 Claims-Made policy without retroactive coverage

 Occurrence policy

Enter the State or States that you are requesting coverage *

Leave this field blank

Thank you! A representative will be in contact with you shortly. If you have any questions, please give our office a call at 480-348-2200.

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