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  • Dental Malpractice Quote Form

  • * Complete the following webform to obtain a malpractice/professional liability policy quote. If you don't know the answer to a question, simply state "I don't know". If the question does not apply, please put a "N/A" in the field. Thank you!

  • Personal Details

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  • Location Details

  • If you will be a new practice owner and this policy is for you as a new practice owner, please complete the rest of this form as if you were already the business owner. For example, list the primary practice address as the new practice, etc.

  • If you are purchasing a practice and the employees of that practice do not know this transition is happening, we highly encourage you to put the billing and mailing address as your home address. After you purchase the practice, we can change those to the office address per your request.

  • Professional Details

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  • Practice/Procedure Details

  • What percentage of your ovarall practicing procedures is dedicated to providiging the above procedures to patients?

  • If you have not had prior coverage, please put N/A in the next few fields asking about that prior coverage

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  • Business Profile

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  • What's the difference between Claims Made and Occurrence? 

    CLICK HERE TO LEARN THE DIFFERENCE

     

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  • Entity

  • If you are a business owner and you have partners, associates, or other dental/medical professionals that come into your practice, you will want to mark "YES" to the entity coverage option above and we also highly recommend you select "YES" to the next question about Vicarious Liability below.

  • Consent and Authorization for Communication

    To allow our agency the ability to provide your requested quote and to effectively schedule an appointment(s) to review that quote, we need to get your authorization to allow Eagleston Financial Group, LLC and our staff to communicate with you by means of emails, phone calls, and SMS text messages. By clicking the checkbox below and providing your email and phone number, you consent and agree to receive messages by those means from Eagleston Financial Group, its agents, and staff.  Your authorization is allowing Eagleston Financial Group, their agents, and staff to also use SMS text messages to effectively communicate with you regarding our programs, offers, marketing, and other information that may be of interest to you.  You also understand that you do not have to agree to receive autodialed or prerecorded calls or texts in order to use and enjoy the products and services offered by Eagleston Financial Group, LLC. You may decline to receive autodialed or prerecorded calls or texts to your mobile phone number in several ways, including by responding with STOP or by emailing the request to opt out with the mobile number, to admin@eagleston.net Your carrier's standard messaging and data rates may apply. To move forward with working with our Eagleston team, please give your authorization below.  Then click the green submit button.
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