Dentists Insurance Premium Indication Request

Your Name

Practice Name

Specialty

Year of Graduation

Year Completion of Residency

Do you perform Third Molar Extractions
YesNo

If yes, ERUPTED, PARTIALLY IMPACTED or FULLY IMPACTED?

ERUPTEDPARTIALLY IMPACTEDFULLY IMPACTED

Do you perform dental implants?
YesNo

If yes, which do you perform the surgical placement?

the implantprosthetic/restorative component

What type(s) of Sedation do you offer your patients, please describe

Have any claims been made against you?
YesNo
If yes, please describe

Current Insurance Company

Claims Madeor Occurrence
Retro Active Date:

Phone

Email

Location Address

City

Zip

County

State

What is your preferred contact method?
PhoneEmail
If phone, what is the best time to call?

Please leave this field empty.

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