ONLINE QUOTE FORM FOR DENTAL/ORAL SURGEONS
PROFESSIONAL LIABILITY INSURANCE

Please answer the questions below by providing as much detail as possible. All information gathered on this form will remain confidential. Before you can submit a Request for Quote, please review our Privacy Policy and HIPAA form, then check this box after you have read, accept and understand them.

Submitted by:

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Agency:

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Mailing Address:

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City:

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State:

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Zipcode:

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Phone Number / Area Code:

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Fax:

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Email Address:

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Applicant`s Instructions:
1. Complete the online form including the claim form if applicable
2. If you have a CV.(resume) please email to pbs@pbsinsurance or fax to 502-254-1056
3. Please DO NOT complete the application earlier than 60 days before the proposed effective date of coverage.

     
 

General Information:
1.
 (a) Full Name:
    Professional Degree:
  (b) Principal practice address:
    City:
  (c) Phone:
   
  (d) Date of Birth (MM/DD/YYYY):
  (e) Social Security No:
2.
 Are you a U.S. citizen? Yes
  If No, what is your status in the U.S. and current citizenship?
3.
 (a)
Type of practice:  
solo practitioner (unincorporated) solo practitioner (incorporated)*
professional corporation* professional association*
limited liability company* partnership*
employee of independent contractor of
other  
*Specify name of entity:
  (b) Do you want coverage for the entity named item 3(a) above? Yes
  (c) If you practice other than as an employee, unincorporated solo practitioner or independent contractor, list the names of all others practicing under the entity name it item 3(a) above.
   
4.
 Do you practice with any dentist not named in item 3(c) above? Yes
  If Yes, provide the name of each dentist and the practice relationship.
     
5.
 Provide the following information for all of the states in which you practice:
 
State
License No.
Effective Date
Expiration Date
Active (Yes/No)
/ /
/ / / / Yes No
/ / / / Yes No
6.
 Federal DEA License No. and status:
7.
 Provide the following information for all hospitals and surgi-centers where you are currently on staff:
 
Name City State Percentage of Work Type of Privileges
8.
 Do you or the entity firm named in item 3(a) above own (either wholly or in part), operate or administer
any hospital, nursing home, surgi-center, urgent care center other facility where medical services are
customarily provided? Yes No
  If Yes, provide a detailed explanation specifically including the name, location, size, and number of beds.
   
     
 

Education and Training:
1. (a) Provide your dental specialty:
  (b) Do you limit your practice to the specialty stated in item (a) above? Yes No
    If No, provide details.
2. Are you American dental board certified in any specialty? Yes No
  If Yes, provide the following: Board(s) in which you are certified:
  Date of certification (MM/DD/YYYY):
  If No, do you plan on taking a Board examination? Yes No
3. Provide the following information:
 
  Name of Institution City State Date Completed
Dental School / /
Internship / /
Specialty      
Residency / /
Specialty      
Fellowship / /
Specialty      
Other / /
Specialty      
4. If you graduated from a foreign dental school, provide the date began
your practice in the United States: / /
5. Provide a detailed summary of where you have practiced your profession since completing your training:
 
Street Address City State Country From
(MM/YYYY) 		To
(MM/YYYY)
/ /
/ /
/ /
6. Indicate the professional organizations which you are a member of:
 
American Society of Dentist Anesthesiologists (ASDA)
American College of OMS (ACOMS)
American Dental Association OMS Society - Other
Other (describe)