Request a quote

Date 
Name 
Address 
City 
State 
Zip 
Phone number 
Fax number 
Type of coverage(s)  Professional Liability
Business Property
Building  
Please complete the following for Professional Liability Quote 
Type of dentist 
Year graduated 
License # 
Classification of anesthesia permit (if applicable in your State) 
Type of anesthesia &/or oral medication used in office 
Insurance company 
Expiration date 
Prior acts  Yes
No
Claims in the last five years (if YES, please respond on separate sheet)  Yes
No
List of dental associations 
Risk management(within three years) 
Please complete the following for Property Quote 
Deductible limit   
Business personal property limit: 
Location #1 
Location #2 
Building limit: 
Location #1 
Location #2 
Please complete the following for Property and/or Building Quote  
Construction of building   
Sprinkler system  Yes
No
Age of building 
Ownership 
 

Completion of this form for a DBIC quick quote neither binds coverage nor guarantees a policy will be issued. DBIC will provide a quick quote based on the information given to us on this form. An accurate premium will be available only after a completed application is received and underwritten. DBIC application may be forwarded to you upon request. If there are any questions or further assistance needed, please call us at (800) 452-0504 or fax (503) 765-3511.