Dental
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 Martha Merritt, Vice President
of Dental Professional Liability, at 888-526-4006. |
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Please call me with premium information. |
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Please send me an application packet. |
| CONTACT
INFORMATION |
| Name: |
|
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| Address: |
|
|
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| E-Mail: |
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| 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.
Full or
Part-time
New Doctor 1st year
2nd year
3rd year |
| 4.
Are you current insured?
Yes
No |
| Policy
Effective Date
|
| 5.
Type of Policy: |
Claims-Made
If so, provide Retroactive/Prior Acts Date
Occurrence
|
| 6.
Limits Requested: |
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$500,000 per
claim/ $1,000,000 Aggregate
$1,000,000
per claim/ $1,000,000 Aggregate
$1,000,000 per claim/ $3,000,000 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: |
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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.
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ALL
QUOTES ARE ONLY AN ESTIMATE.
A PRI application will have to be filled out for an
actual quote.
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