Delaware State Dental Society Quote Form

Life, Health, and
Disability Quote

DSDS Willis of Delaware, formerly PLI, has been the endorsed Professional Liability provider since 1972. In 1999, we also became the endorsed provider for Health Insurance.

Your participation in the the "Dentist's Advantage" program helps support the various important programs of the Delaware State Dental Society. For an obligation-free quote for coverage through the "Dentist's Advantage" Program, please use the form below.

Our Dental Underwriting Specialists:

Name	E-mail	Extension (302-658-8000)
Kurt Taylor		70332
Angel Reed		70356
Marisol Alvarez		70361
I-Li Fox		70337
Sharon Ruth, Underwriting Mgr.		70173
Kathy Maxey, Support Services		70162

Delaware State Dental Society
Professional Liability Insurance
Quote Form

Contact Information
Practice Name:
Contact Name:
Address:
City:
State:	Zip:
Business Phone:
Fax:
E-mail Address:
Dental Specialty:

Professional Liability
1.	Do you use Conscious Sedation? Yes No
2.	Do you use General Anesthesia? Yes No
3.	Are you a Partnership or Corporation? Yes No
4.	Current Limits of Liability:
5.	Type of Coverage:
	If you have Claims Made, what is your Retroactive Date?
	If Yes, how many claims have you had?
6.	Current Insurance Carrier:
7.	Policy Effective Date:
8.	Are you a "New" practitioner within the last 3 years? Yes No
9.	Have you had any professional liability claims in the last 5 years? Yes No
10.	Have you attended a Risk Management Seminar in the last 3 years? Yes No

Property Package
1.	What would it cost to replace the contents of your office, including operatory equipment, furniture, fixtures, records, supplies, improvements and betterments, stock, etc.? $
2.	Do you own the office building? Yes No
	If Yes, what is the current amount of insurance coverage? $
3.	Please check the best description of the construction of the building (only one): Wood Frame Walls Brick or concrete block with wood deck floors and/or ceilings Brick, concrete, or concrete block walls with concrete or metal joist floors/ceilings Fire resistive construction with all metal and/or concrete walls, floors, & ceilings
4.	Does the building have a sprinkler system? Yes No
5.	Are you the only occupant (or occupy 75%) of your building? Yes No

Additional Comments

Please click the "Submit Quote" button to send your quote request.

This is a request for quotation only. No coverage is in effect until bound by an insurance carrier.

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