Online Dentist's Quote
	Return to Dentist's Insurance
	Return Home

If you would like a free, no-obligation Dentist's Insurance quote, please fill out the form below. Once done, click on the Submit button and one of our staff will respond as soon as possible. Contact Information  Name of Firm:  Address:  City/State/Zip:      Phone:  Fax:  Contact Name:  Email Address:  Best Time To Call:   a.m.  p.m.  Do you currently belong to any professional associations?: Y  N     Business Classes Which of the following classes best represents your business operations?      Class 1:   General Dentistry, Endodontics, Pedodontics, Prosthodontics, Orthodontics, Peridontics - Non Osseous, Implant Prostheses - Non Surgical, Removal of Impacted Wisdom Teeth - Soft Tissue Only      Class 2:   Peridontics - Osseous Surgery, Removal of Impacted Wisdom Teeth - Other Than Soft Tissue      Class 3:   Implants - Surgical Property & General Liability  Current Property/Liability Insurance Company:   Are you responsible for the building insurance?:  Yes  No If so, current limit: $ Deductible Amount?: $250 $500 $1,000  What is the contents/personal property limits on your current policy?:  $ Deductible Amount?: $250 $500 $1,000  Is the building sprinklered?:  Yes  No  Is the building less than 10 years old?:  Yes  No  Do you currently offer employee benefits?:  Yes  No Professional Liability  Total Numbers of dentist professionals?:  1 2 3 4 5 6 7 8 9 10 More than 10  How many of these dentist professionals are in their:  1st Year: 1 2 3 4 5 6 7 8 9 10 More than 10 2nd Year: 1 2 3 4 5 6 7 8 9 10 More than 10 3rd Year: 1 2 3 4 5 6 7 8 9 10 More than 10  Are any dentists part time employees?  (< 20 hours per week):  Yes  No  Has each dentist carried consecutive dental professional liability policies?:  Yes  No Auto Liability (Non Owned/Hired Auto liability will be included)  Are there any vehicles currently insured on the  business policy?:  Yes No If Yes, please list the Year, Make, Model and City Garaged in: Year Make Model City Vehicle is Garaged In If there are additional vehicles, use the Additional Comments section below. Workers' Compensation  Current workers compensation company?:   Estimated annual payroll for all employees?:  $ Umbrella/Excess Liability  Amount of quotation on umbrella/excess liability limits:  (The umbrella will go over your professional liability limits) None $1,000,000 $2,000,000 $3,000,000 $5,000,000 Additional Comments Please give any additional comments you feel appropriate for this quotation. Please click on the "Submit Quote" button to send your request. One of our representatives will respond as soon as possible. J.A. Price Agency, Inc. 6640 Shady Oak Road, Suite 500 Eden Prairie, MN 55344 Email: info@japrice.com    Phone:  Toll Free:  Fax:  (952)944-8790 (800)279-1623 (952)944-0097