Get an Indication - Dentists

If you are interested in getting a premium indication, please take a few minutes and fill in the form below. A Premium Group representative will follow up with you shortly.

Name
Birth date	Male Female

Phone
Fax
Email Address
Mailing Address
City
State	Zip Code:
County
Medical School
Graduation Year
Specialty
Hours worked per week

Present Carrier:
Effective Date:
Retro Date:
Type of Coverage:	Claims Made Occurrence



Limits of Liability:
per occurrence annual aggregate


List all dentists, oral surgeons, assistants, technicians, and nurses to be insured.
None


Have you ever had claim/suit, open, closed, settled, or dismissed: Yes No

If yes, please list: You must include Date Closed, Paid Amount, and Reserve Amount for each in the area below:
Do you have any knowledge of any pending claim or complaint: Yes No
If yes, has notice of the claim been presented to the prior carrier: Yes No


I authorize any physician, hospital, clinic, medical facility, medical society, and insurance or reinsurance company to release information necessary to evaluate this application. Furthermore, I understand that this is an application for an insurance quote, not an insurance binder or offer of coverage and that the insurance company will require additional information. Please digitally sign below. Full Name, Title

The Premium Group, Inc. will use this confidential information for the sole purpose of requesting quotes from one or more medical professional liability insurance companies on your behalf.

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