Dentists Benefits
Insurance Company
10505 SE 17th Ave
Milwaukie, OR 97222
503-765-3510
800-452-0504 toll free
503-765-3511 fax

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.