Dental Practice Insurance Form

Step 1 of 8

Step 1 of 8 · Practice

Dental Practice Insurance Intake

Tell us about your practice once. We'll use it to build your insurance options. About 5 to 10 minutes. We save your answers as you go, so you can finish later.

Required.
Entity type
Select one.
Required.
Enter a valid email.
Enter a 10-digit phone number.
Required.

Step 2 of 8 · Location

Where is your practice?

Your main office first. We'll ask about others below.

Required.
Required.
Enter a 5-digit zip.
Required.
Do you own or lease the space?
Select one.
Number of locations
Select one.
Any major renovations planned or underway?
Select one.

Step 3 of 8 · Property & Equipment

Your equipment and contents

What it would cost to replace everything inside your office.

Required.
Any unusually expensive equipment? CBCT, lasers, milling units.
Select one.

Not sure? An estimate is fine. We can help refine it.

Step 4 of 8 · Employees & Payroll

Your team

Counts and an annual payroll estimate are all we need.

Required.
Required.
Required.
Required.
Include owners / officers in workers comp?
Select one.

Step 5 of 8 · Operations

How your practice runs

A few quick questions about operations and vehicles.

Required.
Standard general dentistry?
Select one.
Employees use personal vehicles for business?
Select one.
Any rented or borrowed vehicles?
Select one.
Any business-owned vehicles?
Select one.

Step 6 of 8 · Claims

Any claims in the past 5 years?

Property, liability, workers compensation or auto.

Select one.

If yes, a quick note is enough.

More than one claim? Describe the others here too.

Step 7 of 8 · Current Insurance

What you have today

Skip anything you don't know. Uploading your policy works too.

Upload current policies or proposal
Choose files or drag and drop PDF, photo or scan. Up to 8 MB each.

    Step 8 of 8 · Coverage Preferences

    Which option would you like us to quote first?

    Pick a starting point. We'll tailor it to your practice.

    Pick one to continue.
    Cyber protection
    Select one.

    Dental malpractice / professional liability is handled separately through PIE.

    Please check the box to submit.
    Questions? (801) 622-2626