Mikel's Insurance Services - Dentists Professional Liability Insurance

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Dentists Professional Liability Insurance

Free Premium Estimate Questionnaire (Non-Binding) Indication of Coverage

Click here for a PDF version.

Please answer all questions for a non-binding Premium Estimate.

Part 1

Part 2

Part 3

Practice Information (Please respond as completely as possible.) All sections, except section (D), are required for submission.


(A)	I am a General Dentist or Specialist

	If Specialist, please state Specialty:

(B)	Date I started practicing dentistry: /

(C)	Please check all boxes that apply if you:

		Simple Extracted 3^rd Molars

		Extract Partially Impacted 3^rd Molars

		Extract Fully Impacted 3^rd Molars

		Surgical Placement of Implants

		Perform Botox or Dermal Fillers

(D)	Do you practice full-time or part-time?

	Average Hours per Week:

(E)	Please check all boxes that apply. I am an:

		Employee

		Independent Contractor

		Owner

(F)	Have you had any professional liability claims or incidents within the past 8 years? Yes No

	If Yes, please provide details, status and amounts paid:

Part 4


Please check Per Claim/Aggregate limits in which you are interested:

		$200,000/$600,000

		$500,000/$1,000,000

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

		$2,000,000/$4,000,000

		$3,000,000/$5,000,000

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

		$5,000,000/$7,000,000

Part 5

My current Professional Liability Insurer is:

Expiration Date:

/ / *

Premium:

My current policy is (check one): *

"Claims-Made" with Retro date of:
/ /

Occurrence

Quotations and coverage may be issued only upon acceptance of a fully completed Medical Protective Company application

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