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General Information
Practice Name
First Name
Last Name
Date of Birth
Degree - DDS / DMD / Other
Street Address of Practice
City
State
AK
AL
AR
AS
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MH
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
PW
RI
SC
SD
TN
TX
UT
VA
VI
VT
WA
WI
WV
WY
Zip Code
Telephone
Office Fax
Email
Date you first started practicing as a dentist?
License Number
Contact Person
Request Effective Date
Request Limits of Liability
- Select -
$100,000 / $300,000
$200,000 / $600,000
$250,000 / $750,000
$500,000 / $1,500,000
$1,000,000 / $3,000,000
$3,000,000 / $6,000,000
Deductible
- Select -
$0
$2,500
$5,000
Type of Coverage
Select both if applicable
Claims-Made
Occurrence
Retroactive Effective Date
*
Type of Dentist
Type of Practice
- Select -
Individual
Group
Please list number in group
Dental Specialty
- Select -
General Dentist
Endodontist
Oral Pathologist
Oral Radiologist
Oral Surgeon
Orthodontist
Pediatric Dentist
Prosthodontist
Public Health Dentist
Do you administer I.V. Conscious Sedation, I.M. Conscious Sedation, or Sub-cutaneous conscious sedation as well as perform the dental procedure?
Yes
No
Do you administer and treat patients under I.V. or I.M. conscious sedation or deep sedation or general anesthesia?
Yes
No
Do you perform non simple extractions of full or partially bony impacted teeth?
Yes
No
Does 10% or more of your practice consist of cosmetic dentistry excluding simple bleaching?
Yes
No
Does 25% or more of your practice consist of surgical placement of implants?
Yes
No
Is 25% or more of your practice in the area of oral surgery with no full or partial bony extractions?
Yes
No
How many full mouth reconstruction's (affecting more than 90% of the teeth in the mouth) do you perform each year?
Please estimate the percentage of each surgical procedure provided in your total practice (based on numbers of procedures) on an annual basis. (enter a zero if none)
Implants
Extractions of bony impacted, or partially bony impacted teeth
Other dental cosmetic procedures (excluding biopsies, but including TMJ)
Please provide the percentages of your practice which fall into the following CDT codes (must total 100%)
Diagnostic (D0100 – D0999)
Preventive (D0100 – D0999)
Restorative (D2000 – D2999)
Endodontics (D3000 – D3999)
Periodontics (D4000 – D4999)
Prosthodontics (Removable) (D5000 – D5899)
Maxillofacial Prosthetics (D5900 – D5999)
Implant Services (D6000 – D6199)
Prosthodontics (Fixed) (D6200 – D6999)
Oral and Maxillofacial Surgery (D7000 – D7999)
Orthodontics (D8000 – D8999)
Adjunctive General Services (D9000 – D9999)
Additional Information
How many hours on average do you practice per week?
Do you currently carry malpractice insurance?
Yes
No
Have you ever been involved in a claim?
Yes
No
Expiration Date of Current Policy
Number of open claims
Number of closed claims
Amount Paid or Settled
Date of Claims
Are you a member of the ADA or AGD?
(Post-Grad work, Board Eligible/Certified)
Yes
No
Verification
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