Contact Us:
  By E-Mail
  Phone: (615) 254-5141
  Fax: (615) 244-5796
 
 

Name
Phone Number
Address
Fax Number
City
Type of coverage(s)
 Professional Liability
Business Property
Building
State
Zip
Please complete the following for Professional Liability Quote
Type of Dentist
Insurance Company
Year Graduated
Expiration Date
License #
Prior Acts
 Yes
No
Classification of anesthesia permit
(if applicable in your State)
Claims in the last five years
(If yes, please explain below)
Yes
No
Type of anesthesia &/or oral medication used in office
List of Dental Associations
 
Risk Management(within three years)
 Yes
No
Please complete the following for Property Quote
Deductible Limit
 
Business Personal Property Limit:
Building Limit:
Location #1
Location #1
Location #2
Location #2
Please complete the following for Property and/or Building Quote
Construction of Building
Age of Building
Sprinkler System
 Yes
No
Ownership
   
Claims in the last five years
(If yes, please explain below)
Yes
No

Completion of this form for a DBIC Quick Quote neither binds coverage nor guarantees a policy will be issued. DBIC will provide a Quick Quote based on the information given to us on this form. An accurate premium will be available only after a completed application is received and underwritten. DBIC application may be forwarded to you upon request. If there are any questions or further assistance needed, please call us at (615) 254-5141 or fax (615) 244-5796.