| * First Name: |
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| * Last Name: |
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| Degree: |
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| * Email Address: |
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| Phone: |
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| Fax: |
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| County of Primary Practice: |
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| Street Address: |
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| City: |
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| State: |
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| Zip: |
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| Contact Person |
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| What date did you begin practice? |
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Date you graduated from
Dental School or
completed your Residency: |
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| What type of policy would you like
quoted? |
Occurrence
Claims-made
Both types |
How many hours
per week do you
practice on average? |
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| If you are currently insured and have a
claims-made policy, what is your retroactive date? |
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Limits of Liability you would like quoted
(check all that apply): |
$100,000 / $300,000
$200,000 / $600,000
$250,000 / $750,000
$500,000 / $1,500,000
$1,000,000 / $3,000,000
$2,000,000 / $3,000,000
$3,000,000 / $6,000,000
$4,000,000 / $6,000,000
$5,000,000 / $6,000,000 |
Specialty
(check all that apply): |
Endodontics
Forensic Dentistry
General Dentistry
Oral Pathology
Oral and Maxillofacial Surgery
Orthodontics
Pediatric Dentistry
Periodontics
Prosthodontics
Public Health Dentistry
Sports Dentistry
Other Specialty:
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What types of anesthesia do you administer?
(check all that apply): |
IV Conscious Sedation
IM Conscious Sedation
Sub-Cutaneous Conscious Sedation
General Anesthesia
None |
| Please provide the percentages (based on
number of procedures) of your practice which fall into the following
CDT codes: |
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Do you perform any
surgical procedures? |
YES
NO If
Yes, please estimate the percentage each surgical procedure bears to
your total practice:
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| Have you had any claims? |
YES
NO If
Yes, please give the year of occurrence:
and a brief description:
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| List any Dental or Medical Societies or
Associations in which you are a member: |
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