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!

  • Personal Details

  • Gender*
  • Date of Birth*
     / /
  • Format: (000) 000-0000.

  • Location Details

  • Are you a Practice Owner?*

  • 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.

  • Is the billing address the same as your primary practice address?
  • Is the mailing address the same as your Primary Practice address?
  • Do you own or work at more than one location?*

  • Professional Details

  • Dental School Graduation Date*
     / /
  • Did you complete a residency?*
  • Residency Completion Date*
     / /
  • After completing your initial training, what date did you first enter the practice of dentistry?
     / /
  • License Issue Date*
     / /

  • Practice/Procedure Details

  • Which of the following procedures are performed by you in your practice? Please check all that apply:*

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

  • Are you administering general anesthesia/deep sedation to your patients in your office?*
  • Are you administering intravenous (IV) or intramuscular (IM) conscious sedation to your patients in your office?*
  • Are you administering intravenous (IV) or intramuscular (IM) conscious sedation to your patients in your office?*
  • Do you, or any members of your staff, perform any dental professional services in a prison/jail setting?*
  • Do you, or any member of your staff, perform any dental professional services in a mobile dentistry setting?*
  • Do you, or any member of your staff, perform any dental professional services in a nursing home setting?*
  • In the past 10 years, has any governmental agency, a state licensing board, ever taken action against either your dental and/or narcotics License?*
  • Were you investigated by a state board of dentistry, Medicare and Medicaid billing, and/or any other governmental agency? Check all that apply:*
  • Have you ever been arrested, indicted, pled guilty to, or been convicted of any crime other than minor traffic violations?*
  • In the last 10 years, have you ever been or are currently being treated for alcoholism, drug addiction, mental illness, or physical impairment?*
  • Have you ever had any professional liability insurance refused, cancelled, or non-renewed?*
  • In the last 10 years, has any claim or suit or alleged malpractice ever been brought against you?*
  • Are you currently aware of any situation that could lead to a malpractice suit against you?*
  • Have you reported all potential suits to your existing carrier?*
  • Have you had prior insurance for the past 3 years?*

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

  • Coverage Type:*
  • Effective Date
     / /
  • Expiration Date
     / /
  • What is the Retroactive Date? (This is only if you have a Claims Made policy- this can be found on your certificate of insurance)
     / /
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  • New Policy Details

  • What date would you like to have this new policy effective?*
     / /
  • What type of coverage are you looking for?*

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

    CLICK HERE TO LEARN THE DIFFERENCE

     

  • If Claims Made, what is the retro date? (this can be found on your current certificate of insurance)
     / /

  • Entity Coverage

  • 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.

  • Do you want to add an entity related to the practice of dentistry for which you want coverage?*
  • Do you want your entity to share limits with you personally or have it's own limits in addition to your personal limits?

  • Vicarious Liability

  • CLICK HERE TO LEARN MORE ABOUT VICARIOUS LIABILITY

    (Scroll to the bottom of the page)

  • If you are needing entity coverage, do you also need to add vicarious liability coverage for any clinicians associated with this entity that are not named on your policy?*

  • 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 as well as The Firebird Agency, LLC and their 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 as well as The Firebird Agency, LLC, its agents, and their staff.  Your authorization is allowing Eagleston Financial Group, their agents, and staff as well as The Firebird Agency, LLC, its agents, and their 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 and The Firebird Agency, 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 and Firebird teams, please give your authorization below.  Then click the green submit button.
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