Firebird Dental Malpractice Quote Form

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!
Which Team Member Referred You?*
Personal Details
First Name*
Middle Name
Last Name*
Professional Designation*
Gender*

FemaleMale
Date of Birth*

MonthDayYear
Date
Email*
example@example.com
Cell Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
NPI Number
Location Details
Are you a Practice Owner?*

YES, I'm currently a practice ownerI will be. This policy will be for my new practiceNO
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.
Primary Practice Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What percentage of your time do you work at your Primary Practice?*
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.
Is the billing address the same as your primary practice address?

YesNo
If no, what is the billing address?
Is the mailing address the same as your Primary Practice address?

YesNo
If no, what is the mailing address?
Please list your Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Do you own or work at more than one location?*

YesNo
Please list the names of and addresses of each additional location (if applicable)
Please list the percentage of your time you work at each of the above locations (if applicable)
Professional Details
What Dental School did you attend?*
Dental School Graduation Date*

MonthDayYear
Date
Did you complete a residency?*

YesNo
If yes, please list where you did your residency
Residency Completion Date*

MonthDayYear
Date
After completing your initial training, what date did you first enter the practice of dentistry?

MonthDayYear
Date
How many times did you take the Dental Board Exam?*
Dental License Number (primary state where you will be working)*
License State*
What percentage of your time will you be working in this state?*
License Issue Date*

MonthDayYear
Date
If you hold dental licenses in other states, please list the following: the state, your license number, the date you were issued that license number, and the percentage of your time you are working in that state.
Professional Status*
Dental Specialty*
How many hours per week do you work?*
Practice/Procedure Details
Which of the following procedures are performed by you in your practice? Please check all that apply:*

Cosmetic Dermal Procedures (including but not limited to Botox, Hyaluronic acid products, collagen injections, and dermabrasion. Do not select this if you use these treatments for non-cosmetic procedures).Implant SurgeryExtraction of impacted teethSinus lift surgeryNone of the above
What percentage of your ovarall practicing procedures is dedicated to providiging the above procedures to patients?
Cosmetic Dermal Procedures:*
Implant Surgery:*
Extraction of impacted teeth:*
Sinus lift surgery:*
Are you administering general anesthesia/deep sedation to your patients in your office?*

YesNo
Are you administering intravenous (IV) or intramuscular (IM) conscious sedation to your patients in your office?*

YesNo
Are you administering intravenous (IV) or intramuscular (IM) conscious sedation to your patients in your office?*

YesNo
Do you, or any members of your staff, perform any dental professional services in a prison/jail setting?*

YesNo
Do you, or any member of your staff, perform any dental professional services in a mobile dentistry setting?*

YesNo
Do you, or any member of your staff, perform any dental professional services in a nursing home setting?*

YesNo
In the past 10 years, has any governmental agency, a state licensing board, ever taken action against either your dental and/or narcotics License?*

YesNo
Were you investigated by a state board of dentistry, Medicare and Medicaid billing, and/or any other governmental agency? Check all that apply:*

State Board of DentistryMedicare & Medicaid BillingAny other government entityNone
If you selected any of the above agencies, please explain:
Have you ever been arrested, indicted, pled guilty to, or been convicted of any crime other than minor traffic violations?*

YesNo
In the last 10 years, have you ever been or are currently being treated for alcoholism, drug addiction, mental illness, or physical impairment?*

YesNo
Have you ever had any professional liability insurance refused, cancelled, or non-renewed?*

YesNo
In the last 10 years, has any claim or suit or alleged malpractice ever been brought against you?*

YesNo
Are you currently aware of any situation that could lead to a malpractice suit against you?*

YesNo
If yes, please give details:
Have you reported all potential suits to your existing carrier?*

YesNo
Have you had prior insurance for the past 3 years?*

YesNo
If you have not had prior coverage, please put N/A in the next few fields asking about that prior coverage
Prior Carrier Name*
Coverage Type:*

Claims MadeOccurrenceI had no prior coverage
Incident Limit*
Aggregate Limit*
Effective Date

MonthDayYear
Date
Expiration Date

MonthDayYear
Date
Retroactive Date (if a Claims Made policy)

MonthDayYear
Date
Please Upload a current Certificate of Insurance (COI). If you don't have one, please request one from your current carrier and email that to john@eagleston.net

Cancelof
New Policy Details
What date would you like to have this new policy effective?*

MonthDayYear
Date
What type of coverage are you looking for?*

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

CLICK HERE TO LEARN THE DIFFERENCE
If Claims Made, what is the retro date?

MonthDayYear
Date
What limits of coverage are you requesting? (Per Claim/ Aggregate)*
Entity
Do you want to add an entity related to the practice of dentistry for which you want coverage?*

YesNo
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.
If yes, do you need vicarious liability coverage for any clinicians associated with this entity that are not named on your policy?*

YesNo
Please list the names of each Dr. you want listed for Vicarious Liability along with their specialty (if they are a general dentist, please list "General")
Please list the name of the doctor and the number of hours each week they will be working in your practice
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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