Professional Liability Remarket RequestPlease enable JavaScript in your browser to complete this form. - Step 1 of 2Legal Name: *FirstMiddleLastSuffix:Nickname (if applicable):Email: *Phone: *Preferred Method of Contact (select all that apply) *PhoneEmailTextSpecialty: *Select OneGeneral DentistOral SurgeonPeriodontistEndodontistProsthodontistDental RadiologistPediatric DentistOrthodontistDental PathologistDental AnesthesiologistFirst 6 months of Practice? *YesNoGraduation Date:Graduation Year:Practice name:Practice Zip Code (or City, State): *Practice County (if known):Are you an owner?YesNoRequested Effective Date: *Preferred 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 residency program? *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 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? *Which coverage type do you currently have?Claims Made FormOccurrence FormNot SureWhat is your retroactive date? (highlight year to change):Current Carrier: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 AssociationWhat is MOST important to you in a Malpractice Carrier/Policy? *Claims Experience (Handling & Defense)Consent to Settle (Company cannot settle a claim without your consent)Risk Management Support/CEEasy Renewal (No Annual Application)PriceWhat is 2nd most important to you in a Malpractice Carrier/Policy? *Claims Experience (Handling & Defense)Consent to Settle (Company cannot settle a claim without your consent)Risk Management Support/CEEasy Renewal (No Annual Application)PriceOther information for my advisor:I'm also interested in:Disability InsuranceLife InsuranceHealth InsuranceBusiness Owner's InsuranceHome & Auto InsuranceCustom Captcha * = PreviousEmailSubmit
