Request a Quote Prefer to Talk with Us? 866-279-1252 Call Our Dental Practice Experts Short Quote Form Name* First Last Email* Interested InMalpractice InsuranceBusiness InsuranceWorker's Compensation InsuranceEmployment Practice Liability InsuranceOtherState*Select...AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingCAPTCHA Δ Long Quote Form Step 1 of 5 - Business Info 0% 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 What is your Degree? DDS DMD Can we have our ADA endorsed partner, Equitable Advisors, contact you regarding your retirement plan? Yes No Current policy form*Occurrence formClaims Made formDo you own your practice? Yes No What is the full legal name of your business entity? If Claims made form, give current retroactive date Located on front page of policyCurrent Insurance Company Effective Date of Policy MM slash DD slash YYYY HiddenEffective Date of Policy Liability limits requested $1,000,000 / $3,000,000 $1,300,000 / $3,900,000 (NY Only) $2,000,000 / $4,000,000 $4,000,000 / $6,000,000 $5,000,000 / $7,000,000 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 Is 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 Has your coverage been non-renewed in the past 10 years? Yes No Have you had any licensing or board actions in the past 10 years? Yes No Please list other associations you belong to: Full Legal Name of Business: Business Entity LLC Sole Proprietor Partnership Corporation DBA Name First Last General Practice or Specialist General Practice Specialist Mailing 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 Is the main location address different than the mailing address?* Yes No Main Location 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 How many locations do you have?Please enter a number greater than or equal to 1.Secondary 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 NumberFax NumberEmail How many years have you been in practice?How many years have your practiced at the main location?Date your current business started: MM slash DD slash YYYY Current business owner's coverage insurance carrier Current business owner's insurance premiumCurrent business owner's insurance expiration date MM slash DD slash YYYY Date quote is needed by MM slash DD slash YYYY Have you had any losses or claims in the last 5 years on your buinsess policy? Yes No Please give a description of the loss, the date of the loss, the amount paid and whether the claim is now open or closed.Do you own the building or lease/rent the office space? Own Lease/Rent Year Built Square footage of buildingSquare footage you occupyAre you the only business occupant in your building? Yes No Please list other businesses occupants.Construction Type: Masonry Frame Masonary with wood joists Year of most recent updates (ex. Roof, Heating, Electrical, Plumbing)TypeYear Type of Heat Furnaces Boiler Heat Pump Gas-Fired Space Heaters Unvented Gas-Fired Heaters Electric Space Heaters Wood Burning/Pellet Stoves Fireplace Other Please list age and describe the Boiler systemIs the building 100% sprinklered? Yes No Is there a Burglar Alarm? Yes No Type of Burgular Alarm Local Alarm Central Station Alarm Is there a Fire Alarm? Yes No Type of Fire Alarm Local Alarm Central Station Alarm How many stories is the building?Please enter a number from 1 to 100.Are there elevators in the building? Yes No How many Elevators?What is the building value? (How much is it insured for on current policy)Value of business personal property (i.e. equipment, office furniture, supplies, computers)Any single piece of equipment valued over $20,000? Yes No Describe and give value of equipment valued over $20kDeductible on current policyDo you have a mortgage on the building or a loss payee on the business or business equipment? Yes No Name of lender Address of lender Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Are there any other additional insureds that should be listed? (i.e. Landlord) Yes No List additional insureds Has your business owners or workers compensation policy ever been canceled or non renewed? Yes No Please explain the non-renewal for your policies Federal ID Number Number of full time employees?Number of part time employees?total annual payroll for all employees including owners/officersIf you are incorporated, are the executive officers excluded from coverage? Yes No Amount of payroll for owners/executive officers onlyAnnual Gross ReceiptsDo you have any employment benefit plan? (i.e. health insurance or retirement) Yes No ERISA Required? Yes No Do you have a formal written safety protocol? Yes No Has your business owners or workers compensation policy ever been canceled or non renewed? Yes No Please explain the non-renewal for your policies Δ