Medical Malpractice Quote for Oral and Maxillofacial Surgeons 1Business Info2Current Policy3Underwriting Named Insured* First Last Name of Practice* Principal Practice Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone* Fax Email* Type of Practice:* General Dentistry Orthodontics Oral Surgeon Years in Practice Year Graduated Dental School State License number If you are interested in additional coverage, check an option below and a representative will be in touch to discuss adding a policy. Business Owners Liability Workers Compensation Current policy form*Occurrence formClaims Made formIf Claims made form, give current retroactive date Located on front page of policyCurrent Insurance Company Effective Date of Policy Liability limits requested $250,000 / $750,000 $1,000,000 / $1,000,000 $1,000,000 / $3,000,000 $2,000,000 / $4,000,000 $3,000,000 / $5,000,000 Have any claims been made against you in the past 10 years? Yes No If yes, please provide a brief explanation Are you currently aware of any situation that could lead to a malpractice suit against you? Yes No Do you administer IV/IM conscious sedation? Yes No If Yes, in anesthesia administered in: Office Hospital Surgical Center Do you administer General Anesthesia? Yes No If Yes, in anesthesia administered in: Office Hospital Surgical Center Please indicate if you perform any of the following procedures* Partially impacted 3rd molar extractions Fully impacted 3rd molar extractions Surgical placement of implants Restorative implants Botox or other dermal fillers I perform none of the above Have you taken a Risk Management course in the last 3 years? Yes No Risk Management course date Are you employed 100% by another dentist or dental organization? Yes No How many hours a week do you treat patients? Do you belong to any of the following: ADA AGD AAWD AAP AAPD AAOMS AAE AAO AAPS AACD Other Please list other associations you belong to: HiddenForm Page URL CAPTCHA Δ