Test Form PagePlease enable JavaScript in your browser to complete this form. – Step 1 of 2Select Coverage to be Quoted (select all that apply):Professional Liability (Malpractice) – Coverage for your work with patientsDisability Income – Protects your ability to continue to receive an income equal to your education and training in the event of an accident or illnessLegal Name: *FirstMiddleLastSuffix:Nickname (if applicable):Email: *Phone: *Preferred Method of Contact (select all that apply): *PhoneEmailTextSpecialty: *Select OneGeneral DentistOral SurgeonPeriodontistEndodontistProsthodontistDental RadiologistPediatric DentistOrthodontistDental PathologistDental AnesthesiologistUniversity / Program Attended: *Graduation Date: *Employer/Practice Name (if known):Thinking of opening your own practice in the future?YesNoRequested Effective Date: *Professional Liability (Malpractice): The following selections will impact the company we recommend & future pricing. It is best to select only the items you know you will be performing.Select procedures you will perform:Placement of ImplantsExtract Partially Impacted TeethExtract Soft Tissue Impacted TeethExtract Full Bony Impacted TeethEndo Multi-Rooted TeethOrthodonticsTherapeutic BotoxCosmetic BotoxDermo FillersSelect the procedures you will perform:Elective facial cosmetic surgeryRhinoplastyRhytidectomyOtoplastyBlepharoplastyBreast AugmentationLiposuctionSelect all types of anesthesia you know you will administer:LocalNitrousOral Sedation (single dose of anxiety drug combined with nitrous)* Multiple Dose Oral Sedation (multiple doses of anxiety drug with nitrous)IV/IM 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.Practice Zip Code (or City, State): *Form of coverage requested: *Claims MadeOccurrenceNot SureDisability Insurance: The following information will allow us to provide you with competitive quotes from several high quality carriers.Date of Birth *MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender: *MaleFemaleHeight:Weight:Are you currently taking any medications? *YesNoPlease list:NextHow did you hear about us?WebinarFriend/ColleagueOnline SearchFinancial AdvisorBankerSocial Media PostOtherWho?Which one?Other *I'm Also Interested In (select all that apply:Term Life InsuranceHealth InsuranceHome/Renters & Auto InsuranceAdditional information for my advisor:Custom Captcha * = PreviousSubmit
