Associate In Practice Quote FormPlease enable JavaScript in your browser to complete this form. - Step 1 of 2I am looking for...I am looking for...Professional Liability (Malpractice) InsuranceDisability InsuranceLife InsuranceHealth InsurancePrefer to complete offline? No problem! Download Form Upload FormLegal Name: *FirstMiddleLastSuffix:Nickname (if applicable):Email: *Phone: *Home Zip Code: *Preferred Method of Contact (select all that apply) *PhoneEmailTextDate of Birth: *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender: *MaleFemaleRequested Effective Date of Coverage: *Specialty: *Select OneGeneral DentistOral SurgeonPeriodontistEndodontistProsthodontistDental RadiologistPediatric DentistOrthodontistDental PathologistDental AnesthesiologistNew to Practice? *YesNoAre you considering practice ownership?YesNoGraduation Date:Graduation Year:Employer: *Practice Zip Code:Practice County (if known):Do you work an average of 30 hours or more a week?YesNoInformation for Professional Liability (Malpractice) Insurance Quote:Preferred Professional Liability (Malpractice) Coverage Type *Claims MadeOccurrenceNot SureIs your practice limited to Endodontics?YesNoIs your practice limited to Radiology?YesNoIs your practice limited to Orthodontics? YesNoIs your practice limited to Pathology? YesNoDid you attend a formal Dental Anesthesiology Residency? *YesNoSelect all the procedures you perform:Placement of ImplantsExtract Partially Impacted TeethExtract Soft Tissue Impacted TeethExtract Full Bony Impacted TeethEndo Multi-Rooted TeethOrthodonticsTherapeutic BotoxCosmetic BotoxDermo FillersSelect all the procedures you perform:Elective facial cosmetic surgeryRhinoplastyRhytidectomyOtoplastyBlepharoplastyBreast augmentationLiposuctionSelect all types of anesthesia you administer:LocalNitrousOral Sedation (single dose of anxiety drug combined with nitrous)* Multiple Dose Oral Sedation (more than one dose of anxiety drug on day of procedure combined with Nitrous)IV/IM Conscious SedationGeneral Anesthesia* Please note that a combination of drugs or cocktail given as a single dose in conjunction with nitrous is still single dose oral sedation.Have you ever had a malpractice claim and/or state board sanction? *YesNoDo you currently have Professional Liability (Malpractice) coverage? *YesNoHave you been practicing without Professional Liability (Malpractice) coverage for more than 20 days? *YesNoHow long have you been practicing without Professional Liability (Malpractice) coverage? *Current Professional Liability (Malpractice) Carrier:Which Professional Liability (Malpractice) coverage type do you currently have?Claims Made FormOccurrence FormNot SureWhat is your retroactive date? (highlight year to change):Information for Disability Income Insurance Quote:Monthly Disability Income Benefit Amount to Quote (select one):Preferred Benefit AmountMax Available Based on IncomeMonthly Benefit Amount: *Estimated Annual Earned Income: *Do you currently have Disability Income coverage?YesNoCurrent Carrier:Benefit Amount:Will you be replacing existing coverage?YesNoInformation for Life Insurance Quote:Amount of Life Insurance coverage to quote? (select all that apply)$500,000$1,000,000$2,000,000$3,000,000Other Amount - list in advisor info sectionTerm length to quote? (select all that apply)10 Years20 Years30 YearsLifetimeOther Amount - list in advisor info sectionInformation for Health Insurance Quote:List below Name, Gender and Date of Birth for anyone else to be covered on your health insurance policyDisability & Life Insurance requires both medical and financial underwriting. The following questions will allow us to provide a more accurate quote.If you prefer to answer these questions offline please call us at 972-663-5190 to speak to an advisor, or download a printable PDF and upload below or fax to 214.635.1099 Download Form Upload FormHeight:Weight:Any tobacco use in the last 12 months?YesNoAre you currently taking any medications?YesNoPlease list:Annual Earned Income:NextInformation for Discounts:In the last 12 months, have you completed a risk management course?YesNoAssociation Membership (select all that apply):State Dental AssociationADAAGDAGD MasterAGD FellowSpecialty AssociationHow did you hear about us?I'm also interested in:Home & Auto InsuranceFlood InsuranceOther information for my advisor:Custom Captcha * = PreviousSubmit
