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DENTAL PROFESSIONAL LIABILITY QUOTE FORM
Dental Malpractice Insurance Quote
General Information
Contact Name *
Email *
Business Name
Address
City
State
Zip
County
Business Phone
Fax
Business Insurance
Business Insurance
Type of Policy
Occurrence
Claims-Made
I am a
General Dentist
Specialist
My Specialty is
Has any claim or suit for alleged malpractice been brought against you in the last 5 years?
Yes
No
# of Hours Worked Each Week
Year Graduated
Current Insurance Carrier
Limit of Liability
I have completed a risk management seminar in the last 3 years
Yes
No
* = Required Field
Disclaimer Notice
- The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.
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