Quick Quote for Dentists

Quick Quote

Please use this Quick Quote form to submit your current info to PRI, so that we may give you a fast estimate on coverage costs. Or, contact Brian Dalton, Vice President of Dental Professional Liability, at 888-526-4006.

5. Type of Policy:
Fields with a * are required.
Please call me with premium information.
Please send me an application packet.
CONTACT INFORMATION
Name: *
Address: *
City: *
State: *
Zip: *
Contact Name: *
Telephone: *
FAX:
E-Mail: *
PROFESSIONAL LIABILITY INSURANCE INFORMATION
1. Primary Office Location (County only): *	(if more than one location, please indicate where you practice more than 50% of the time)
2. Years in practice?*
3. Coverage Time:*	Full Time Part Time New Doctor 1st year 2nd year 3rd year
4. Are you current insured? *	Yes No
Policy Effective Date:*
Claims-Made:*
If so, provide Retroactive/Prior Acts Date:
Occurrence:
6. Limits Requested:*	$500,000 per claim/ $1,000,000 Aggregate $1000,000 per claim/ $1,000,000 Aggregate $1,000,000 per claim / $3,000,000 Aggregate $2,000,000 per claim / $6,000,000 Aggregate
7. Taken Risk Management Course in last three years?: *	Yes No
8. Willing to give PRI authorization to settle claims on your behalf?: *	Yes No
9. MagnaCare Member?: *	Yes No
10. Number of claims paid by an INSURANCE COMPANY on your behalf in the past 5 years: *	0 1 2
11. Comments:
Please note: Premium indications will be provided based on the above information. In addition, there are scheduled credit/debits up to 15% which you may be eligible for and which can only be determined upon recipt of a completed application. This form does not guarantee coverage. An application must still be completed for a policy to be issued. All premiums are subject to underwriting review of a completed application.

ALL QUOTES ARE ONLY AN ESTIMATE. A PRI application will have to be filled out for an actual quote.

Quick Quote for Dentists

Quick Quote

CONTACT INFORMATION

PROFESSIONAL LIABILITY INSURANCE INFORMATION