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Contact Us

508 Twilight Trail, Ste 203
Richardson, TX 75080
972-663-5190
advisor@wallacesig.com
Hours of Operation:
Monday – Friday 8:30 AM to 5:00 PM CST

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Disability & Life Insurance Form

- Step 1 of 5

No time? No problem!

Download Form Upload Form

We provide competitive quotes from multiple high quality carriers based on an "own occupation" definition with our agency's minimum recommended coverage. An advisor will contact you, after the initial proposal is delivered, to discuss further customization of the policy to meet your needs.

Legal Name: *

First

Middle

Last

Suffix:

Nickname (if applicable):

Date of Birth (highlight year to change): *

Gender: *

Male
Female

Email: *

Phone: *

Preferred Method of Contact (select all that apply): *

Phone
Email
Text

Zip Code: *

Occupation:

Include specialty, if applicable

Current Employer:

Employment Experience (choose one):

New Graduate
Resident
Established in Practice

Graduation Year:

Do you work an average of 30 hours or more a week?

Yes
No

Are you a practice owner?

Yes
No

Coverage Options (select all that apply)

Individual Disability Income

* In case you are ever too sick or too hurt to work, this is a policy that will help replace your personal income to take care of bills and other personal expenses.

Business Owner's Disability Overhead Expense

* As a business owner, you will be reimbursed for the overhead expenses of the business should you ever be too sick or too hurt to work.

Business Owner's Disability Business Loan Protection

* If you have a loan for your business, then you know that your lender will expect repayment whether the business is open or not. This policy will pay the principal and interest portions of your payment should you ever be too sick or too hurt to work.

Monthly Benefit Amount to Quote (select one):

Preferred Benefit Amount
Max Available Based on Income

Monthly Benefit Amount:

Annual Earned Income:

Do you currently have coverage?

Yes
No

Current Carrier:

Benefit Amount:

Will you be replacing existing coverage?

Yes
No

Select Benefit Option:

Estimated Monthly Overhead Expenses
Determine Based off Current P&L or Tax Return (please submit via Email (advisor@wallacesig.com) or Fax (214.635.1099)

Estimated Monthly Overhead Expenses:

Estimated Monthly Loan Payment Amount:

Estimated Date of First Loan Payment (highlight year to change):

Estimated Payoff Date (highlight year to change):

Disability 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 Form

Estimate Annual Earned Income:

Height:

Weight:

Are you currently taking any medications?

Yes
No

Please list:

How did you hear about us?

I'm also interested in:

Life Insurance
Professional Liability (Malpractice)
Health Insurance
Home & Auto Insurance
Business Owner's Insurance

Other information for my advisor:

Associate In Practice Quote Form

- Step 1 of 2

I am looking for...

I am looking for...

Professional Liability (Malpractice) Insurance
Disability Insurance
Life Insurance
Health Insurance

Prefer to complete offline? No problem!

Download Form Upload Form

Legal Name: *

First

Middle

Last

Suffix:

Nickname (if applicable):

Email: *

Phone: *

Home Zip Code: *

Preferred Method of Contact (select all that apply) *

Phone
Email
Text

Date of Birth (highlight year to change): *

Gender: *

Male
Female

Requested Effective Date of Coverage: *

Specialty: *

New to Practice? *

Yes
No

Are you considering practice ownership?

Yes
No

Graduation Date:

Graduation Year:

Employer: *

Practice Zip Code:

Practice County (if known):

Do you work an average of 30 hours or more a week?

Yes
No

Information for Professional Liability (Malpractice) Insurance Quote:

Preferred Professional Liability (Malpractice) Coverage Type *

Claims Made
Occurrence
Not Sure

Is your practice limited to Endodontics?

Yes
No

Is your practice limited to Radiology?

Yes
No

Is your practice limited to Orthodontics?

Yes
No

Is your practice limited to Pathology?

Yes
No

Did you attend a formal Dental Anesthesiology Residency? *

Yes
No

Select all the procedures you perform:

Placement of Implants
Extract Partially Impacted Teeth
Extract Soft Tissue Impacted Teeth
Extract Full Bony Impacted Teeth
Endo Multi-Rooted Teeth
Orthodontics
Therapeutic Botox
Cosmetic Botox
Dermo Fillers

Select all the procedures you perform:

Elective facial cosmetic surgery
Rhinoplasty
Rhytidectomy
Otoplasty
Blepharoplasty
Breast augmentation
Liposuction

Select all types of anesthesia you administer:

Local
Nitrous
Oral 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 Sedation
General 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? *

Yes
No

Do you currently have Professional Liability (Malpractice) coverage? *

Yes
No

Have you been practicing without Professional Liability (Malpractice) coverage for more than 20 days? *

Yes
No

How 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 Form
Occurrence Form
Not Sure

What 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 Amount
Max Available Based on Income

Monthly Benefit Amount: *

Estimated Annual Earned Income: *

Do you currently have Disability Income coverage?

Yes
No

Current Carrier:

Benefit Amount:

Will you be replacing existing coverage?

Yes
No

Information for Life Insurance Quote:

Amount of Life Insurance coverage to quote? (select all that apply)

$500,000
$1,000,000
$2,000,000
$3,000,000
Other Amount - list in advisor info section

Term length to quote? (select all that apply)

10 Years
20 Years
30 Years
Lifetime
Other Amount - list in advisor info section

Information for Health Insurance Quote:

List below Name, Gender and Date of Birth for anyone else to be covered on your health insurance policy

Disability & 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 Form

Height:

Weight:

Any tobacco use in the last 12 months?

Yes
No

Are you currently taking any medications?

Yes
No

Please list:

Annual Earned Income:

Information for Discounts:

In the last 12 months, have you completed a risk management course?

Yes
No

Association Membership (select all that apply):

State Dental Association
ADA
AGD
AGD Master
AGD Fellow
Specialty Association

How did you hear about us?

I'm also interested in:

Home & Auto Insurance
Flood Insurance

Other information for my advisor:

Small Group Health Insurance Quote Form

- Step 1 of 3

Prefer to complete offline? No problem!

Download Form Upload Form

Requested Effective Date: *

Doctor/Owner's Name(s): *

Type of Business: *

Company Entity (Legal) Name: *

Email *

Phone *

Insurance Contact (if different):

Preferred Method of Contact (select all that apply): *

Phone
Email
Text

Zip Code: *

All Employees & Spouse/Dependents to be Covered:

Please provide a census that includes Employee (or Spouse/Dependent) Name, Date of Birth, and Gender (select one):

Send us your census via email (advisor@wallacesig.com), fax (214.635.1099) Download Form Upload Form
Enter information

1. Name:

First

Last

Date of Birth:

Gender:

Male
Female

Coverage for spouse or dependent?

Yes
No

Is this person a (select one):

Spouse
Dependent

2. Name:

First

Last

Date of Birth:

Gender:

Male
Female

Coverage for spouse or dependent?

Yes
No

Is this person a (select one):

Spouse
Dependent

3. Name:

First

Last

Date of Birth:

Gender:

Male
Female

Coverage for spouse or dependent?

Yes
No

Is this person a (select one):

Spouse
Dependent

4. Name:

First

Last

Date of Birth:

Gender:

Male
Female

Coverage for spouse or dependent?

Yes
No

Is this person a (select one):

Spouse
Dependent

5. Name:

First

Last

Date of Birth:

Gender:

Male
Female

Coverage for spouse or dependent?

Yes
No

Is this person a (select one):

Spouse
Dependent

6. Name:

First

Last

Date of Birth:

Gender:

Male
Female

Coverage for spouse or dependent?

Yes
No

Is this person a (select one):

Spouse
Dependent

How did you hear about us?

I'm interested in the following employee benefits:

Group Dental Insurance
Group Vision Insurance
Group Life Insurance
Group Short Term Disability Insurance
Group Long Term Disability Insurance
Voluntary employee paid insurance (cancer, critical illness, etc.)

I'm also interested in:

Office Property/General Liabilty
Worker's Compensation
Data Breach / Cyber Liability
Employment Practices Liability
Professional Liability (Malpractice)
Disability for Business Owners
Term Life
Personal Home & Auto

Additional information for my advisor:

Individual/Family Health Insurance Quote Form

- Step 1 of 3

Prefer to complete offline? No problem!

Download Form Upload Form

Requested Effective Date: *

Primary Policyholder's Name: *

First

Middle

Last

Suffix:

Date of Birth (highlight year to change): *

Gender: *

Male
Female

Tobacco Use? *

Yes
No

Email *

Phone *

Preferred Method of Contact (select all that apply): *

Phone
Email
Text

Zip Code: *

Type of Coverage Preferred (select one):

HMO
PPO

Additional - Type of Coverage Preferred (select one):

High Deductible/HSA Compatible
Lower Deductible with Co-pays
Show Me Options

All Individuals to be Covered:

1. Name:

First

Last

Date of Birth:

Gender:

Male
Female

Tobacco Use?

Yes
No

2. Name:

First

Last

Date of Birth:

Gender:

Male
Female

Tobacco Use?

Yes
No

3. Name:

First

Last

Date of Birth:

Gender:

Male
Female

Tobacco Use?

Yes
No

4. Name:

First

Last

Date of Birth:

Gender:

Male
Female

Tobacco Use?

Yes
No

5. Name:

First

Last

Date of Birth:

Gender:

Male
Female

Tobacco Use?

Yes
No

6. Name:

First

Last

Date of Birth:

Gender:

Male
Female

Tobacco Use?

Yes
No

How did you hear about us?

I'm also interested in:

Disability Income Insurance
Professional Liability (Malpractice)
Life Insurance
Business Owner's Insurance
Personal Home/Auto/Umbrella
Flood Insurance

Additional information for my advisor:

Disability Insurance Quote Form

- Step 1 of 4

Prefer to complete offline? No problem!

Download Form Upload Form

We provide competitive quotes from multiple high quality carriers based on an "own occupation" definition with our agency's minimum recommended coverage. An advisor will contact you, after the initial proposal is delivered, to discuss further customization of the policy to meet your needs.

Legal Name: *

First

Middle

Last

Suffix:

Nickname (if applicable):

Date of Birth (highlight year to change): *

Gender: *

Male
Female

Email: *

Phone: *

Preferred Method of Contact (select all that apply): *

Phone
Email
Text

Zip Code: *

Occupation: *

Include specialty, if applicable

Current Employer:

Employment Experience: *

New Graduate
Resident
Established in Practice

Graduation Date:

Do you work an average of 30 hours or more a week?

Yes
No

Are you a practice owner?

Yes
No

Coverage Options (select all that apply)

Individual Disability Income

* In case you are ever too sick or too hurt to work, this is a policy that will help replace your personal income to take care of bills and other personal expenses.

Business Owner's Disability Overhead Expense

* As a business owner, you will be reimbursed for the overhead expenses of the business should you ever be too sick or too hurt to work.

Business Owner's Disability Business Loan Protection

* If you have a loan for your business, then you know that your lender will expect repayment whether the business is open or not. This policy will pay the principal and interest portions of your payment should you ever be too sick or too hurt to work.

Monthly Benefit Amount to Quote (select one):

Preferred Benefit Amount
Max Available Based on Income

Monthly Benefit Amount:

Annual Earned Income:

Do you currently have coverage?

Yes
No

Current Carrier:

Benefit Amount:

Will you be replacing existing coverage?

Yes
No

Select Benefit Option:

Estimated Monthly Overhead Expenses
Determine Based off Current P&L or Tax Return (please submit via Email (advisor@wallacesig.com) or Fax (214.635.1099)

Estimated Monthly Overhead Expenses:

Estimated Monthly Loan Payment Amount:

Estimated Date of First Loan Payment (highlight year to change):

Estimated Payoff Date (highlight year to change):

Disability 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 Form

Estimated Annual Earned Income:

Height:

Weight:

Are you currently taking any medications?

Yes
No

Please list:

How did you hear about us?

I'm also interested in:

Life Insurance
Professional Liability (Malpractice)
Health Insurance
Home & Auto Insurance
Business Owner's Insurance
Flood Insurance

Other information for my advisor:

Group Benefit Quote Form

- Step 1 of 3

Prefer to complete offline? No problem!

Download Form Upload Form

Requested Effective Date: *

Company Entity (Legal) Name: *

Practice Name/DBA (if applicable):

FEIN:

Doctor/Owner's Name(s): *

Insurance Contact (if different):

Email: *

Phone: *

Preferred Method of Contact (select all that apply): *

Phone
Email
Text

Physical Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address (if different):

Address Line 1

Address Line 2

City

State

Zip Code

Please provide an employee census that includes Employee Name, Date of Birth, and Gender as well as salary and occupation if group life and/or disability is requested (select one):

Send us your census via email (advisor@wallacesig.com), fax (214.635.1099) or upload Download Form Upload Form
Enter information

1. Name:

First

Last

Date of Birth:

Gender:

Male
Female

Salary:

Occupation:

2. Name:

First

Last

Date of Birth:

Gender:

Male
Female

Salary:

Occupation:

3. Name:

First

Last

Date of Birth:

Gender:

Male
Female

Salary:

Occupation:

4. Name:

First

Last

Date of Birth:

Gender:

Male
Female

Salary:

Occupation:

Select to Add More Employees/Spouses/Dependents

5. Name:

First

Last

Date of Birth:

Gender:

Male
Female

Salary:

Occupation:

6. Name:

First

Last

Date of Birth:

Gender:

Male
Female

Salary:

Occupation:

7. Name:

First

Last

Date of Birth:

Gender:

Male
Female

Salary:

Occupation:

How did you hear about us?

I'm interested in the following employee benefits: *

Group Health Insurance
Group Dental Insurance
Group Vision Insurance
Group Life Insurance
Group Short Term Disability Insurance
Group Long Term Disability Insurance
Voluntary employee paid insurance (cancer, critical illness, etc.)

I'm also interested in:

Office Property/General Liabilty
Worker's Compensation
Data Breach / Cyber Liability
Employment Practices Liability
Professional Liability (Malpractice)
Disability for Business Owners
Term Life
Personal Home & Auto
Flood Insurance

Other information for my advisor:

Group Practice Protector Quote Form

- Step 1 of 2

Prefer to answer offline? No problem!

Download Form Upload Form

Requested Effective Date: *

Doctor/Owner's Name(s): *

Insurance Contact (if different):

Email: *

Phone: *

Preferred Method of Contact (select all that apply) *

Phone
Email
Text

Company (Legal) Name: *

Practice Name/DBA (if applicable):

Date Established: *

FEIN(s):

Number of locations:

Primary Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address (if different):

Address Line 1

Address Line 2

City

State

Zip Code

Do you own any buildings?

Yes
No

Owned Locations:

Is your practice the only occupant?

Yes
No

Standard Business Owner's Policies Exclude Coverage for Losses Due to Floods & Earthquakes:

Would you like a quote for flood insurance?

Yes
No

Would you like a quote for earthquake insurance?

Yes
No

Number of Support Employees:

Annual Payroll, excluding owners/officers:

Number of Associates (Include W2 & Contractor):

Do you currently have a group professional liability policy?

Yes
No
Please Quote

Current Policy Carrier:

Current Policy Expiration Date (highlight year to change):

Do you pay for or reimburse associates for malpractice?

Yes
No

Do you provide health insurance for your employees?

Yes
No

Does your business have a 401K or pension plan?

Yes
No

Do you own any vehicles in the name of the practice?

Yes
No

Year, Make & Model of Vehicle:

How did you hear about us?

I'm also interested in:

Higher Limits for Data Breach | Cyber Liability
Higher Limits for Employment Practice Liability
Directors & Officers Liability
Key Man Disability
Disability Buy/Sell
Life Buy/Sell

Additional information for my advisor:

Worker's Compensation Quote Form

- Step 1 of 3

Prefer to complete offline? No problem!

Download Form Upload Form

Requested Effective Date: *

Doctor/Owner's Name(s): *

Email: *

Phone: *

Preferred Method of Contact (select all that apply): *

Phone
Email
Text

Company (Legal) Name: *

Practice Name/DBA (if applicable):

Date Established:

FEIN:

Physical Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address (if different):

Address Line 1

Address Line 2

City

State

Zip Code

Number of Support Employees: *

Number of Doctors on Staff (Including W2 & Contractor): *

Annual Payroll, without owners/officers: *

How did you hear about us?

I'm also interested in:

Office Property/General Liabilty
Professional Liability (Malpractice)
Employment Practices Liability
Data Breach | Cyber Liability
Disability Insurance
Life Insurance
Health Insurance
Personal Home & Auto Insurance
Flood Insurance

Additional information for my advisor:

Office Property | General Liability Quote Form

- Step 1 of 4

Prefer to complete offline? No problem!

Requested Effective Date: *

Doctor/Owner's Name(s): *

Email: *

Phone: *

Preferred Method of Contact (select all that apply): *

Phone
Email
Text

Company (Legal) Name: *

Practice Name/DBA (if applicable):

FEIN:

Year Business Established:

Physical Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address (if different):

Address Line 1

Address Line 2

City

State

Zip Code

Square Feet Occupied:

Do you own the building? *

Yes
No

Estimated Replacement Cost of Building:

Is this a condo unit?

Yes
No

Are you the only occupant?

Yes
No

Amount of coverage for Business Personal Property:

contents, equipment, finish out, furniture, etc.

Do you own any vehicle in the name of the practice?

Yes
No

Year, Make & Model of Vehicle:

Standard Business Owner's Policies Exclude Coverage for Losses Due to Floods & Earthquakes:

Would you like a quote for flood insurance?

Yes
No

Would you like a quote for earthquake insurance?

Yes
No

How did you hear about us?

I'm also interested in:

Worker's Compensation
Higher Limits for Data Breach | Cyber Liability
Higher Limits for Employment Practices Liability
Professional Liability (Malpractice)
Disability Income
Life Insurance
Health Insurance
Personal Home & Auto

Additional information for my advisor:

Employment Practices Liability Quote Form

- Step 1 of 2

Prefer to complete offline? No problem!

Download Form Upload Form

Requested Effective Date: *

Doctor/Owner's Name(s): *

Email: *

Phone: *

Preferred Method of Contact (select all that apply): *

Phone
Email
Text

Company (Legal) Name: *

Practice Name/DBA (if applicable):

Date Established *

FEIN:

Physical Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address (if different):

Address Line 1

Address Line 2

City

State

Zip Code

Number of Employees: *

Annual Revenue: *

How did you hear about us?

I'm also interested in:

Office Property/General Liability
Worker's Compensation
Professional Liability (Malpractice)
Data Breach/Cyber Liability
Disability Income
Term Life Insurance
Health Insurance
Personal Home & Auto

Additional information for my advisor:

Data Breach | Cyber Liability Quote Form

- Step 1 of 2

Prefer to complete offline? No problem!

Download Form Upload Form

Requested Effective Date: *

Doctor/Owner's Name(s): *

Email: *

Phone: *

Preferred Method of Contact (select all that apply): *

Phone
Email
Text

Company (Legal) Name: *

Practice Name/DBA (if applicable):

Date Established

FEIN:

Number of Doctors in Practice: *

Physical Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address (if different):

Address Line 1

Address Line 2

City

State

Zip Code

How did you hear about us?

I'm also interested in:

Office Property/General Liabilty
Worker's Compensation
Employment Practices Liability
Professional Liability (Malpractice)
Disability Income
Life Insurance
Health Insurance
Personal Home & Auto
Flood Insurance

Additional information for my advisor:

Term Life Quote Form

- Step 1 of 3

Prefer to complete offline? No problem!

Download Form Upload Form

Legal Name: *

First

Middle

Last

Suffix:

Nickname (if applicable):

Date of Birth (highlight year to change): *

Gender: *

Male
Female

Email: *

Phone: *

Postal Code: *

Preferred Method of Contact (select all that apply): *

Phone
Email
Text

How much coverage do you need? (select one): *

Enter Amount
Not sure, contact me to determine

Amount:

Length of policy term (select all options of interest): *

10 Years
20 Years
30 Years
Lifetime

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 Form

Height:

Weight:

Any tobacco use in the last 12 months?

Yes
No

Are you currently taking any medications?

Yes
No

Please list:

Any family history of cancer, diabetes or heart disease?

Yes
No

Please list:

How did you hear about us?

I'm also interested in:

Disability Income
Professional Liability (Malpractice)
Health Insurance
Home & Auto Insurance
Business Owner's Insurance
Flood Insurance

Additional information for my advisor:

Personal Home & Auto Quote Form

- Step 1 of 6

Prefer to complete offline? No problem!

Download Form Upload Form

Legal Name: *

First

Middle

Last

Suffix:

Nickname (if applicable):

Email: *

Phone: *

Preferred Method of Contact (select all that apply): *

Phone
Email
Text

Home Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Information for All Drivers:

1. Name:

First

Last

License Number:

Date of Birth:

2. Name:

First

Last

License Number:

Date of Birth:

3. Name:

First

Last

License Number:

Date of Birth:

4. Name:

First

Last

License Number:

Date of Birth:

Year of last plumbing update or repair:

Year or last roof update or repair:

Have you had any claims in the past 5 years?

Yes
No

What year did you purchase your home?

Select all that apply:

Enclosed pool with privacy fence or gate
Pool not enclosed by privacy fence or gate
Monitored alarm sysem
Accidents or Tickets in the past 5 years

Additional information to quote (select one):

Send us your current policy: email (advisor@wallacesig.com), fax (214.635.1099) or Upload Form
Enter information

Home Insurance:

Estimated Replacement Cost of Home:

Is the home under construction?

Yes
No

Is there a business on the premises?

Yes
No

Current Homeowner's Carrier:

Expiration Date (highlight year to change):

Has the property insurance been cancelled, declined or non-renewed in the last 5 years?

Yes
No

Auto Insurance:

Name of Primary Driver:

First

Last

Gender:

Male
Female

Occupation:

1. Additional Driver Name:

First

Last

Gender:

Male
Female

Occupation:

2. Additional Driver Name:

First

Last

Gender:

Male
Female

Occupation:

3. Additional Driver Name:

First

Last

Gender:

Male
Female

Occupation:

Vehicle Information:

1. Year:

Make:

Model:

Estimated Annual Mileage:

2. Year:

Make:

Model:

Estimated Annual Mileage:

Lender's name:

Lender's Address (if applicable):

Address Line 1

Address Line 2

City

State

Zip Code

Auto Carrier (if different from home owners):

Expiration date (highlight year to change):

Additional Coverage Requested:

Road side assistance
Car Rental coverage
Jewelry Coverage
Fine Art Coverage
Umbrella coverage over $1,000,000

Jewelry Amount:

Fine Art Amount:

Umbrella Coverage Amount:

Standard Homeowner's Policies Exclude Coverage for Losses Due to Floods & Earthquakes:

Would you like a quote for flood insurance?

Yes
No

Would you like a quote for earthquake insurance?

Yes
No

How did you hear about us?

I'm also interested in:

Disability Income
Life Insurance
Health Insurance
Business Owner's Insurance

Additional information for my advisor:

Practice Protector Quote Form

- Step 1 of 3

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Requested Effective Date: *

Doctor/Owner's Name(s): *

Email: *

Phone: *

Preferred Method of Contact (select all that apply): *

Phone
Email
Text

Company (Legal) Name: *

Practice Name (DBA if applicable):

FEIN:

Date Business Established: *

Physical Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Mailing Address (if different):

Address Line 1

Address Line 2

City

State

Zip Code

Business Owner's Policy:

Includes Property, Liability and other important coverage for a business owner

Do you own the building?

Yes
No

Are you the only occupant?

Yes
No

Estimated Replacement Cost of Building:

Square Feet Occupied: *

Is this a condo unit?

Yes
No

Amount of coverage for Business Personal Property: *

In a worst case scenario: what would it cost to replace all contents, equipment, finish out, furniture, etc.

Standard Business Owner's Policies Exclude Coverage for Losses Due to Floods & Earthquakes:

Would you like a quote for flood insurance?

Yes
No

Would you like a quote for earthquake insurance?

Yes
No

Worker's Compensation:

Number of Support Employees:

Number of Doctors on Staff (Including W2 & Contractor):

Annual Payroll, excluding owners/officers:

Other Coverage:

Do you pay for, or reimburse, associates for their malpractice?

Yes
No

Do you provide health insurance for your employees?

Yes
No

Does your business have a 401K or pension plan?

Yes
No

If you are too sick or hurt to work, do you have enough disability insurance to:

Keep your practice doors open?

Yes
No

Continue to make your loan payment(s)?

Yes
No

Do you own any vehicles in the name of the practice?

Yes
No

Year, Make & Model of Vehicle:

How did you hear about us?

I'm also interested in:

Professional Liability (Malpractice)
Entity Professional Liability (Malpractice)
Health Insurance
Higher Limits for Data Breach / Cyber Liability
Higher Limits for Employment Practices Liability
Life Insurance
Personal Home & Auto Insurance

Additional information for my advisor:

New Graduate Quote Form

- Step 1 of 2

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Select Coverage to be Quoted (select all that apply):

Professional Liability (Malpractice) - Coverage for your work with patients
Disability Income - Protects your ability to continue to receive an income equal to your education and training in the event of an accident or illness

Legal Name: *

First

Middle

Last

Suffix:

Nickname (if applicable):

Email: *

Phone: *

Preferred Method of Contact (select all that apply): *

Phone
Email
Text

Specialty: *

University / Program Attended: *

Graduation Date: *

Employer/Practice Name (if known):

Thinking of opening your own practice in the future?

Yes
No

Requested 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 Implants
Extract Partially Impacted Teeth
Extract Soft Tissue Impacted Teeth
Extract Full Bony Impacted Teeth
Endo Multi-Rooted Teeth
Orthodontics
Therapeutic Botox
Cosmetic Botox
Dermo Fillers

Select the procedures you will perform:

Elective facial cosmetic surgery
Rhinoplasty
Rhytidectomy
Otoplasty
Blepharoplasty
Breast Augmentation
Liposuction

Select all types of anesthesia you know you will administer:

Local
Nitrous
Oral Sedation (single dose of anxiety drug combined with nitrous)
* Multiple Dose Oral Sedation (multiple doses of anxiety drug with nitrous)
IV/IM Sedation
General 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 Made
Occurrence
Not Sure

Disability Insurance: The following information will allow us to provide you with competitive quotes from several high quality carriers.

Date of Birth (highlight year to change) *

Gender: *

Male
Female

Height:

Weight:

Are you currently taking any medications? *

Yes
No

Please list:

How did you hear about us?

I'm Also Interested In (select all that apply:

Term Life Insurance
Health Insurance
Home/Renters & Auto Insurance

Additional information for my advisor:

Professional Liability (Malpractice) Quote Form

- Step 1 of 2

Prefer to complete offline? No problem!

Download Form Upload Form

Legal Name: *

First

Middle

Last

Suffix:

Nickname (if applicable):

Email: *

Phone: *

Preferred Method of Contact (select all that apply) *

Phone
Email
Text

Specialty: *

New to Practice? *

Yes
No

Graduation Date:

Graduation Year:

Practice name:

Practice Zip Code (or City, State): *

Practice County (if known):

Are you an owner?

Yes
No

Requested Effective Date: *

Preferred Coverage Type *

Claims Made
Occurrence
Not Sure

Is your practice limited to Endodontics?

Yes
No

Is your practice limited to Radiology?

Yes
No

Is your practice limited to Orthodontics?

Yes
No

Is your practice limited to Pathology?

Yes
No

Did you attend a formal residency program? *

Yes
No

Select all the procedures you perform:

Placement of Implants
Extract Partially Impacted Teeth
Extract Soft Tissue Impacted Teeth
Extract Full Bony Impacted Teeth
Endo Multi-Rooted Teeth
Orthodontics
Therapeutic Botox
Cosmetic Botox
Dermo Fillers

Select all the procedures you perform:

Elective facial cosmetic surgery
Rhinoplasty
Rhytidectomy
Otoplasty
Blepharoplasty
Breast augmentation
Liposuction

Select all types of anesthesia you administer:

Local
Nitrous
Oral 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 Sedation
General 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? *

Yes
No

Do you currently have coverage? *

Yes
No

Have you been practicing without Professional Liability (Malpractice) coverage for more than 20 days? *

Yes
No

How long have you been practicing without Professional Liability (Malpractice) coverage? *

Which coverage type do you currently have?

Claims Made Form
Occurrence Form
Not Sure

What is your retroactive date? (highlight year to change):

Current Carrier:

Information for Discounts:

In the last 12 months, have you completed a risk management course?

Yes
No

Association Membership (select all that apply):

State Dental Association
ADA
AGD
AGD Master
AGD Fellow
Specialty Association

How did you hear about us?

I'm also interested in:

Disability Insurance
Life Insurance
Health Insurance
Business Owner's Insurance
Home & Auto Insurance

Other information for my advisor: