Allsouth Professional Liability, Inc.
Dentists Qucik - Quote Request


Dentist Name
Address

City
State
Zip
County
Phone
Fax
Email



1.Requested effective Date: monthdayyear

2. My current policy is written on: Claims made coverage Occurance Coverage
If claims made, what is the Retro Date? monthdayyear

3. Current insurance Company limits Premium.

Requested Limits (Check all the limits you would like quoted)

$ 100,000 / $ 300,000 $ 2,000,000 / $ 3,000,000
$ 200,000 / $ 600,000 $ 3,000,000 / $ 6,000,000
$ 500,000 / $ 1,500,000 $ 4,000,000 / $ 6,000,000
$ 1,000,000 / $ 3,000,000 $ 5,000,000 / $ 6,000,000



4. IV / IM Sedation YesNo

5. General Anesthesia? YesNo

6. What is your practice specialty?

7. Are there other Dentist in your practice? YesNo - If yes, how many?

8. Are you a "New" practitioner (newly licensed within the past three years) ? YesNo

9. Do you practice 20 hours or less per week? YesNo

10. Have you attended a rish management seminar within the past 3 years? YesNo

11. Have you had any professional liability claims in the past 5 years? YesNo
If yes, please provide description of claim, date of claim, total paid, reserve amount or claimants settlement demand.

12. Does your current policy include General Liability? YesNo

13. Are you interested in Worker's Compensation Insurance? YesNo
If yes, number of employees. Gross anual payroll?

14. Property Protection (excluding Broward, Dade,Monroe & Palm Beach counties)
Do you own your office building?YesNo If yes, what is replacement cost?
Estimate replacement costs for contents of your office. $ (include fixtures ,equipment ,records, supplies, etc.
Building Construction:
Wood frame walls
Brick and concrete wall with wood deck floors and/or ceilings
Brick andconcrete walls with concrete or metal joists floors and/or ceilings
"Fire Resistive" construction with all metal and/or concrete walls, floors and ceilings
Does your builing have a sprinker system for fire protection? YesNo
Are you the only occupant (or occupy at least 75% of your building? YesNo

Important Note: This is not an application for insurance. The information provided will allow us to offer you an indication of the cost of insurance.

Allsouth Professional Liability, Inc.
5444 Bay Center Drive, Suite 216
Tampa, Fl 33609
Phone: 813.288.0990 or 800.913.9260
Fax: 813.282.0994

Contact Terri Galentine - tgalentine@allsouth.net