A. General Information

B. Coverage Information

C. Education

Training and education

If you own the practice or have a legal entity (for tax purposes, etc.), please answer all questions in Section D. If you are not a practice owner and have no legal entity, mark N/A for questions 1 and 2.

** For every employee dentist, independent contractor dentist and other officer or partner, a separate application OR proof of current professional liability coverage must be attached (upload on the last page).

Patient makeup by payment type (enter 0 if none)

You may be eligible for a premium discount. Please upload a letter from the school acknowledging your position.

Procedures

Based on your answers to questions 9 through 12, a supplemental application may be required.

Percentage of procedures you perform (by number of procedures) in each CDT code range. Must total 100%.

Do you currently perform any of the following?

Estimated % of your total practice for each (by number of procedures, annually; total need not equal 100%)

E. Office Procedures

Working less than 20 hours per week? You may qualify for a part-time discount. Please explain the reason and who handles emergencies when you are out of the office in the comments on the last page.

F. Anesthetics and Analgesia

Nitrous oxide used solely as an analgesic is not considered conscious sedation.

G. Other Exposure Information

Additional insureds requested on the policy (name and address; leave blank if none)

Have you ever:

Business Liability (Option 2): in the last 5 years, have any claims been made against you arising out of:

I. Premises Information and Payroll

For a Business Owners (property) or Workers’ Compensation quote, please complete the following.

Supplemental Claim Information

Complete one block for each claim, suit or board complaint. More than two? Upload a separate sheet below.

Claim 1

Claim 2

I understand the information submitted here becomes part of my Professional Liability Application as submitted.

Attachments & Comments

Please attach, as applicable:
• A copy of your current declarations page (if a new applicant)
• If currently insured, a current loss run from your current insurance carrier
• A copy of your practice letterhead
• Certificate of insurance or declarations pages for all independent contractor and employee dentists
• A copy of your dental license
• A copy of your conscious sedation permit or license (if applicable)
• Copies of certificates for implant courses taken
• Current letter of faculty appointment
• Copies of all correspondence, orders and stipulations received from the dental board
• A Supplemental Claim Information sheet for each claim (if any)
• Proof of coverage from your employer, hospital, clinic or dental school

Representations, Fraud Warning & Signature

By signing this application you, the applicant, agree with the insurer that:
A. You have made a comprehensive internal inquiry to determine whether anyone in your organization is aware of any actual or alleged fact, circumstance, situation, act, error or omission which may reasonably be expected to result in a claim, and have disclosed any and all such situations in Section H, questions 1 and 2 of this application.
B. This application and its attachments, and all statements and answers given in them, are: (1) accurate and complete to the best of your knowledge; (2) representations you are making on behalf of all persons and entities proposed to be covered; and (3) a material inducement to the insurer to provide a proposal for insurance, and any policy issued is issued in specific reliance upon these representations.
C. You agree to report to the insurer in writing any material change in your operations, conditions or answers provided in this application that occurs or is discovered after the completion date of this application and before the effective date of the policy. On receipt of such notice, the insurer may modify or withdraw any proposal for insurance, at its sole discretion.
D. You authorize the insurer, its agents and representatives to obtain claims information from your current and previous insurance carriers.
E. The discovery of any fraud, intentional concealment or misrepresentation of a material fact will make the policy, if issued, void from inception.
F. If this application is for claims-made coverage, only claims first made against you and reported to the insurer during the policy period or any applicable extended reporting period are covered, subject to the policy provisions.

FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false, incomplete or misleading information, or conceals, for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and may subject the person to criminal and civil penalties, including fines, imprisonment and denial of insurance benefits. State-specific fraud notices (including AR, CO, DC, FL, KS, KY, LA, ME, MD, MN, NJ, NM, NY, OH, OK, OR, PA, RI, TN, VA, VT, WA and WV) apply and will be provided by the insurer where required.

By checking "I Accept", the applicant consents and agrees that using a keypad, mouse or other device to check "I Accept" constitutes the applicant's signature, acceptance and agreement as if signed by the applicant in writing, with the same force and effect as a handwritten signature. The applicant also agrees that the lack of a certification authority or other third-party verification will not affect the validity or enforceability of the signature or any resulting contract. Signing this application does not bind the applicant or the insurer to complete the insurance.