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Alex Ford
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×
Disability & Life Insurance Form
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We provide competitive quotes from multiple high quality carriers based on an "own occupation" definition with our agency's minimum recommended coverage. An advisor will contact you, after the initial proposal is delivered, to discuss further customization of the policy to meet your needs.
Legal Name:
*
First
Middle
Last
Suffix:
Nickname (if applicable):
Date of Birth:
*
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1931
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1926
1925
1924
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1921
1920
Gender:
*
Male
Female
Email:
*
Phone:
*
Preferred Method of Contact (select all that apply):
*
Phone
Email
Text
Zip Code:
*
Next
Occupation:
Include specialty, if applicable
Current Employer:
Employment Experience (choose one):
New Graduate
Resident
Established in Practice
Graduation Year:
Previous
Next
Do you work an average of 30 hours or more a week?
Yes
No
Are you a practice owner?
Yes
No
Coverage Options (select all that apply)
Individual Disability Income
* In case you are ever too sick or too hurt to work, this is a policy that will help replace your personal income to take care of bills and other personal expenses.
Business Owner's Disability Overhead Expense
* As a business owner, you will be reimbursed for the overhead expenses of the business should you ever be too sick or too hurt to work.
Business Owner's Disability Business Loan Protection
* If you have a loan for your business, then you know that your lender will expect repayment whether the business is open or not. This policy will pay the principal and interest portions of your payment should you ever be too sick or too hurt to work.
Monthly Benefit Amount to Quote (select one):
Preferred Benefit Amount
Max Available Based on Income
Monthly Benefit Amount:
Annual Earned Income:
Do you currently have coverage?
Yes
No
Current Carrier:
Benefit Amount:
Will you be replacing existing coverage?
Yes
No
Select Benefit Option:
Estimated Monthly Overhead Expenses
Determine Based off Current P&L or Tax Return
(please submit via Email (advisor@wallacesig.com) or Fax (214.635.1099)
Estimated Monthly Overhead Expenses:
Estimated Monthly Loan Payment Amount:
Estimated Date of First Loan Payment (highlight year to change):
Estimated Payoff Date (highlight year to change):
Previous
Next
Disability Insurance requires both medical and financial underwriting. The following questions will allow us to provide a more accurate quote.If you prefer to answer these questions offline please call us at
972-663-5190
to speak to an advisor, or download a printable PDF and upload below or fax to
214.635.1099
Download Form
Upload Form
Estimate Annual Earned Income:
Height:
Weight:
Are you currently taking any medications?
Yes
No
Please list:
Previous
Next
How did you hear about us?
I'm also interested in:
Life Insurance
Professional Liability (Malpractice)
Health Insurance
Home & Auto Insurance
Business Owner's Insurance
Other information for my advisor:
Custom Captcha
*
What is 7+4?
Previous
Submit
×
Associate In Practice Quote Form
Please enable JavaScript in your browser to complete this form.
-
Step
1
of 2
I am looking for...
I am looking for...
Professional Liability (Malpractice) Insurance
Disability Insurance
Life Insurance
Health Insurance
Prefer to complete offline? No problem!
Download Form
Upload Form
Legal Name:
*
First
Middle
Last
Suffix:
Nickname (if applicable):
Email:
*
Phone:
*
Home Zip Code:
*
Preferred Method of Contact (select all that apply)
*
Phone
Email
Text
Date of Birth:
*
MM
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YYYY
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
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1930
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1926
1925
1924
1923
1922
1921
1920
Gender:
*
Male
Female
Requested Effective Date of Coverage:
*
Specialty:
*
Select One
General Dentist
Oral Surgeon
Periodontist
Endodontist
Prosthodontist
Dental Radiologist
Pediatric Dentist
Orthodontist
Dental Pathologist
Dental Anesthesiologist
New to Practice?
*
Yes
No
Are you considering practice ownership?
Yes
No
Graduation Date:
Graduation Year:
Employer:
*
Practice Zip Code:
Practice County (if known):
Do you work an average of 30 hours or more a week?
Yes
No
Information for Professional Liability (Malpractice) Insurance Quote:
Preferred Professional Liability (Malpractice) Coverage Type
*
Claims Made
Occurrence
Not Sure
Is your practice limited to Endodontics?
Yes
No
Is your practice limited to Radiology?
Yes
No
Is your practice limited to Orthodontics?
Yes
No
Is your practice limited to Pathology?
Yes
No
Did you attend a formal Dental Anesthesiology Residency?
*
Yes
No
Select all the procedures you perform:
Placement of Implants
Extract Partially Impacted Teeth
Extract Soft Tissue Impacted Teeth
Extract Full Bony Impacted Teeth
Endo Multi-Rooted Teeth
Orthodontics
Therapeutic Botox
Cosmetic Botox
Dermo Fillers
Select all the procedures you perform:
Elective facial cosmetic surgery
Rhinoplasty
Rhytidectomy
Otoplasty
Blepharoplasty
Breast augmentation
Liposuction
Select all types of anesthesia you administer:
Local
Nitrous
Oral Sedation (single dose of anxiety drug combined with nitrous)
* Multiple Dose Oral Sedation (more than one dose of anxiety drug on day of procedure combined with Nitrous)
IV/IM Conscious Sedation
General Anesthesia
* Please note that a combination of drugs or cocktail given as a single dose in conjunction with nitrous is still single dose oral sedation.
Have you ever had a malpractice claim and/or state board sanction?
*
Yes
No
Do you currently have Professional Liability (Malpractice) coverage?
*
Yes
No
Have you been practicing without Professional Liability (Malpractice) coverage for more than 20 days?
*
Yes
No
How long have you been practicing without Professional Liability (Malpractice) coverage?
*
Current Professional Liability (Malpractice) Carrier:
Which Professional Liability (Malpractice) coverage type do you currently have?
Claims Made Form
Occurrence Form
Not Sure
What is your retroactive date? (highlight year to change):
Information for Disability Income Insurance Quote:
Monthly Disability Income Benefit Amount to Quote (select one):
Preferred Benefit Amount
Max Available Based on Income
Monthly Benefit Amount:
*
Estimated Annual Earned Income:
*
Do you currently have Disability Income coverage?
Yes
No
Current Carrier:
Benefit Amount:
Will you be replacing existing coverage?
Yes
No
Information for Life Insurance Quote:
Amount of Life Insurance coverage to quote? (select all that apply)
$500,000
$1,000,000
$2,000,000
$3,000,000
Other Amount - list in advisor info section
Term length to quote? (select all that apply)
10 Years
20 Years
30 Years
Lifetime
Other Amount - list in advisor info section
Information for Health Insurance Quote:
List below Name, Gender and Date of Birth for anyone else to be covered on your health insurance policy
Disability & Life Insurance requires both medical and financial underwriting. The following questions will allow us to provide a more accurate quote.If you prefer to answer these questions offline please call us at
972-663-5190
to speak to an advisor, or download a printable PDF and upload below or fax to
214.635.1099
Download Form
Upload Form
Height:
Weight:
Any tobacco use in the last 12 months?
Yes
No
Are you currently taking any medications?
Yes
No
Please list:
Annual Earned Income:
Next
Information for Discounts:
In the last 12 months, have you completed a risk management course?
Yes
No
Association Membership (select all that apply):
State Dental Association
ADA
AGD
AGD Master
AGD Fellow
Specialty Association
How did you hear about us?
Webinar
Friend/Colleague
Online Search
Financial Advisor
Banker
Social Media Post
Other
Who?
Other
*
Which one?
I'm also interested in:
Home & Auto Insurance
Flood Insurance
Other information for my advisor:
Custom Captcha
*
=
Previous
Submit
×
Small Group Health Insurance Quote Form
Please enable JavaScript in your browser to complete this form.
-
Step
1
of 3
Prefer to complete offline? No problem!
Download Form
Upload Form
Requested Effective Date:
*
Doctor/Owner's Name(s):
*
Type of Business:
*
Company Entity (Legal) Name:
*
Email
*
Phone
*
Insurance Contact (if different):
Preferred Method of Contact (select all that apply):
*
Phone
Email
Text
Zip Code:
*
Next
All Employees & Spouse/Dependents to be Covered:
Please provide a census that includes Employee (or Spouse/Dependent) Name, Date of Birth, and Gender (select one):
Send us your census via email (advisor@wallacesig.com), fax (214.635.1099)
Download Form
Upload Form
Enter information
1. Name:
First
Last
Date of Birth:
Gender:
Male
Female
Coverage for spouse or dependent?
Yes
No
Is this person a (select one):
Spouse
Dependent
2. Name:
First
Last
Date of Birth:
Gender:
Male
Female
Coverage for spouse or dependent?
Yes
No
Is this person a (select one):
Spouse
Dependent
3. Name:
First
Last
Date of Birth:
Gender:
Male
Female
Coverage for spouse or dependent?
Yes
No
Is this person a (select one):
Spouse
Dependent
4. Name:
First
Last
Date of Birth:
Gender:
Male
Female
Coverage for spouse or dependent?
Yes
No
Is this person a (select one):
Spouse
Dependent
5. Name:
First
Last
Date of Birth:
Gender:
Male
Female
Coverage for spouse or dependent?
Yes
No
Is this person a (select one):
Spouse
Dependent
6. Name:
First
Last
Date of Birth:
Gender:
Male
Female
Coverage for spouse or dependent?
Yes
No
Is this person a (select one):
Spouse
Dependent
Previous
Next
How did you hear about us?
Webinar
Friend/Colleague
Online Search
Financial Advisor
Banker
Social Media Post
Other
Who?
Other
*
Which one?
I'm interested in the following employee benefits:
Group Dental Insurance
Group Vision Insurance
Group Life Insurance
Group Short Term Disability Insurance
Group Long Term Disability Insurance
Voluntary employee paid insurance (cancer, critical illness, etc.)
I'm also interested in:
Office Property/General Liabilty
Worker's Compensation
Data Breach / Cyber Liability
Employment Practices Liability
Professional Liability (Malpractice)
Disability for Business Owners
Term Life
Personal Home & Auto
Additional information for my advisor:
Custom Captcha
*
=
Previous
Submit
×
Individual/Family Health Insurance Quote Form
Please enable JavaScript in your browser to complete this form.
-
Step
1
of 3
Prefer to complete offline? No problem!
Download Form
Upload Form
Requested Effective Date:
*
Primary Policyholder's Name:
*
First
Middle
Last
Suffix:
Date of Birth (highlight year to change):
*
Gender:
*
Male
Female
Tobacco Use?
*
Yes
No
Email
*
Phone
*
Preferred Method of Contact (select all that apply):
*
Phone
Email
Text
Zip Code:
*
Type of Coverage Preferred (select one):
HMO
PPO
Additional - Type of Coverage Preferred (select one):
High Deductible/HSA Compatible
Lower Deductible with Co-pays
Show Me Options
Next
All Individuals to be Covered:
1. Name:
First
Last
Date of Birth:
Gender:
Male
Female
Tobacco Use?
Yes
No
2. Name:
First
Last
Date of Birth:
Gender:
Male
Female
Tobacco Use?
Yes
No
3. Name:
First
Last
Date of Birth:
Gender:
Male
Female
Tobacco Use?
Yes
No
4. Name:
First
Last
Date of Birth:
Gender:
Male
Female
Tobacco Use?
Yes
No
5. Name:
First
Last
Date of Birth:
Gender:
Male
Female
Tobacco Use?
Yes
No
6. Name:
First
Last
Date of Birth:
Gender:
Male
Female
Tobacco Use?
Yes
No
Previous
Next
How did you hear about us?
Webinar
Friend/Colleague
Online Search
Financial Advisor
Banker
Social Media Post
Other
Who?
Which one?
Other
*
I'm also interested in:
Disability Income Insurance
Professional Liability (Malpractice)
Life Insurance
Business Owner's Insurance
Personal Home/Auto/Umbrella
Flood Insurance
Additional information for my advisor:
Custom Captcha
*
=
Previous
Submit
×
Disability Insurance Quote Form
Please enable JavaScript in your browser to complete this form.
-
Step
1
of 4
Prefer to complete offline? No problem!
Download Form
Upload Form
We provide competitive quotes from multiple high quality carriers based on an "own occupation" definition with our agency's minimum recommended coverage. An advisor will contact you, after the initial proposal is delivered, to discuss further customization of the policy to meet your needs.
Legal Name:
*
First
Middle
Last
Suffix:
Nickname (if applicable):
Date of Birth:
*
MM
1
2
3
4
5
6
7
8
9
10
11
12
DD
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
YYYY
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Gender:
*
Male
Female
Email:
*
Phone:
*
Preferred Method of Contact (select all that apply):
*
Phone
Email
Text
Zip Code:
*
Occupation:
*
Include specialty, if applicable
Current Employer:
Employment Experience:
*
New Graduate
Resident
Established in Practice
Graduation Date:
Next
Do you work an average of 30 hours or more a week?
Yes
No
Are you a practice owner?
Yes
No
Coverage Options (select all that apply)
Individual Disability Income
* In case you are ever too sick or too hurt to work, this is a policy that will help replace your personal income to take care of bills and other personal expenses.
Business Owner's Disability Overhead Expense
* As a business owner, you will be reimbursed for the overhead expenses of the business should you ever be too sick or too hurt to work.
Business Owner's Disability Business Loan Protection
* If you have a loan for your business, then you know that your lender will expect repayment whether the business is open or not. This policy will pay the principal and interest portions of your payment should you ever be too sick or too hurt to work.
Monthly Benefit Amount to Quote (select one):
Preferred Benefit Amount
Max Available Based on Income
Monthly Benefit Amount:
Annual Earned Income:
Do you currently have coverage?
Yes
No
Current Carrier:
Benefit Amount:
Will you be replacing existing coverage?
Yes
No
Select Benefit Option:
Estimated Monthly Overhead Expenses
Determine Based off Current P&L or Tax Return
(please submit via Email (advisor@wallacesig.com) or Fax (214.635.1099)
Estimated Monthly Overhead Expenses:
Estimated Monthly Loan Payment Amount:
Estimated Date of First Loan Payment (highlight year to change):
Estimated Payoff Date (highlight year to change):
Previous
Next
Disability Insurance requires both medical and financial underwriting. The following questions will allow us to provide a more accurate quote.If you prefer to answer these questions offline please call us at
972-663-5190
to speak to an advisor, or download a printable PDF and upload below or fax to
214.635.1099
Download Form
Upload Form
Estimated Annual Earned Income:
Height:
Weight:
Are you currently taking any medications?
Yes
No
Please list:
Previous
Next
How did you hear about us?
Webinar
Friend/Colleague
Online Search
Financial Advisor
Banker
Social Media Post
Other
Who?
Which one?
Other
*
I'm also interested in:
Life Insurance
Professional Liability (Malpractice)
Health Insurance
Home & Auto Insurance
Business Owner's Insurance
Flood Insurance
Other information for my advisor:
Captcha
*
=
Previous
Submit
×
Group Benefit Quote Form
Please enable JavaScript in your browser to complete this form.
-
Step
1
of 3
Prefer to complete offline? No problem!
Download Form
Upload Form
Requested Effective Date:
*
Company Entity (Legal) Name:
*
Practice Name/DBA (if applicable):
FEIN:
Doctor/Owner's Name(s):
*
Insurance Contact (if different):
Email:
*
Phone:
*
Preferred Method of Contact (select all that apply):
*
Phone
Email
Text
Physical Address:
*
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Mailing Address (if different):
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Next
Please provide an employee census that includes Employee Name, Date of Birth, and Gender as well as salary and occupation if group life and/or disability is requested (select one):
Send us your census via email (advisor@wallacesig.com), fax (214.635.1099) or upload
Download Form
Upload Form
Enter information
1. Name:
First
Last
Date of Birth:
Gender:
Male
Female
Salary:
Occupation:
2. Name:
First
Last
Date of Birth:
Gender:
Male
Female
Salary:
Occupation:
3. Name:
First
Last
Date of Birth:
Gender:
Male
Female
Salary:
Occupation:
4. Name:
First
Last
Date of Birth:
Gender:
Male
Female
Salary:
Occupation:
Select to Add More Employees/Spouses/Dependents
5. Name:
First
Last
Date of Birth:
Gender:
Male
Female
Salary:
Occupation:
6. Name:
First
Last
Date of Birth:
Gender:
Male
Female
Salary:
Occupation:
7. Name:
First
Last
Date of Birth:
Gender:
Male
Female
Salary:
Occupation:
Previous
Next
How did you hear about us?
I'm interested in the following employee benefits:
*
Group Health Insurance
Group Dental Insurance
Group Vision Insurance
Group Life Insurance
Group Short Term Disability Insurance
Group Long Term Disability Insurance
Voluntary employee paid insurance (cancer, critical illness, etc.)
I'm also interested in:
Office Property/General Liabilty
Worker's Compensation
Data Breach / Cyber Liability
Employment Practices Liability
Professional Liability (Malpractice)
Disability for Business Owners
Term Life
Personal Home & Auto
Flood Insurance
Other information for my advisor:
Custom Captcha
*
=
Previous
Submit
×
Group Practice Protector Quote Form
Please enable JavaScript in your browser to complete this form.
-
Step
1
of 2
Requested Effective Date:
*
Doctor/Owner's Name(s):
*
Insurance Contact (if different):
Email:
*
Phone:
*
Preferred Method of Contact (select all that apply)
*
Phone
Email
Text
Company (Legal) Name:
*
Practice Name/DBA (if applicable):
Date Established:
*
FEIN(s):
Number of locations:
Primary Location Address:
*
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Mailing Address (if different):
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Second Location Address
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
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Washington
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State
Zip Code
Third Location Address:
Address Line 1
Address Line 2
City
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Wisconsin
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State
Zip Code
Fourth Location Address:
Address Line 1
Address Line 2
City
--- Select state ---
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Utah
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Fifth Location Address:
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
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Delaware
District of Columbia
Florida
Georgia
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Indiana
Iowa
Kansas
Kentucky
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Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
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Montana
Nebraska
Nevada
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New Jersey
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New York
North Carolina
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Ohio
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Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Do you own any buildings?
Yes
No
Owned Locations:
Is your practice the only occupant?
Yes
No
Standard Business Owner's Policies Exclude Coverage for Losses Due to Floods & Earthquakes:
Would you like a quote for flood insurance?
Yes
No
Would you like a quote for earthquake insurance?
Yes
No
Number of Support Employees:
Annual Payroll, excluding owners/officers:
Number of Associates (Include W2 & Contractor):
Do you currently have a group professional liability policy?
Yes
No
Please Quote
Current Policy Carrier:
Current Policy Expiration Date (highlight year to change):
Do you pay for or reimburse associates for malpractice?
Yes
No
Do you provide health insurance for your employees?
Yes
No
Does your business have a 401K or pension plan?
Yes
No
Do you own any vehicles in the name of the practice?
Yes
No
Year, Make & Model of Vehicle:
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Requested Effective Date:
*
Doctor/Owner's Name(s):
*
Email:
*
Phone:
*
Preferred Method of Contact (select all that apply):
*
Phone
Email
Text
Next
Company (Legal) Name:
*
Practice Name/DBA (if applicable):
Date Established:
FEIN:
Physical Address:
*
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
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Indiana
Iowa
Kansas
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Maine
Maryland
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Michigan
Minnesota
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Montana
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New York
North Carolina
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Ohio
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Rhode Island
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Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Mailing Address (if different):
Address Line 1
Address Line 2
City
--- Select state ---
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Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
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Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
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Nevada
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New Jersey
New Mexico
New York
North Carolina
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Ohio
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Rhode Island
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South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
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State
Zip Code
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Number of Support Employees:
*
Number of Doctors on Staff (Including W2 & Contractor):
*
Annual Payroll, without owners/officers:
*
How did you hear about us?
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Requested Effective Date:
*
Doctor/Owner's Name(s):
*
Email:
*
Phone:
*
Preferred Method of Contact (select all that apply):
*
Phone
Email
Text
Next
Company (Legal) Name:
*
Practice Name/DBA (if applicable):
FEIN:
Year Business Established:
Physical Address:
*
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
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State
Zip Code
Mailing Address (if different):
Address Line 1
Address Line 2
City
--- Select state ---
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Alaska
Arizona
Arkansas
California
Colorado
Connecticut
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District of Columbia
Florida
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Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
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Ohio
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Tennessee
Texas
Utah
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Washington
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State
Zip Code
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Square Feet Occupied:
Do you own the building?
*
Yes
No
Estimated Replacement Cost of Building:
Is this a condo unit?
Yes
No
Are you the only occupant?
Yes
No
Amount of coverage for Business Personal Property:
contents, equipment, finish out, furniture, etc.
Do you own any vehicle in the name of the practice?
Yes
No
Year, Make & Model of Vehicle:
Standard Business Owner's Policies Exclude Coverage for Losses Due to Floods & Earthquakes:
Would you like a quote for flood insurance?
Yes
No
Would you like a quote for earthquake insurance?
Yes
No
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Requested Effective Date:
*
Doctor/Owner's Name(s):
*
Email:
*
Phone:
*
Preferred Method of Contact (select all that apply):
*
Phone
Email
Text
Company (Legal) Name:
*
Practice Name/DBA (if applicable):
Date Established
*
FEIN:
Physical Address:
*
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Mailing Address (if different):
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Number of Employees:
*
Annual Revenue:
*
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Webinar
Friend/Colleague
Online Search
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Banker
Social Media Post
Other
Other
*
Who?
Which one?
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Requested Effective Date:
*
Doctor/Owner's Name(s):
*
Email:
*
Phone:
*
Preferred Method of Contact (select all that apply):
*
Phone
Email
Text
Company (Legal) Name:
*
Practice Name/DBA (if applicable):
Date Established
FEIN:
Number of Doctors in Practice:
*
Physical Address:
*
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Mailing Address (if different):
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
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Webinar
Friend/Colleague
Online Search
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Other
Who?
Which one?
Other
*
I'm also interested in:
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Worker's Compensation
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Term Life Quote Form
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Legal Name:
*
First
Middle
Last
Suffix:
Nickname (if applicable):
Date of Birth:
*
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Gender:
*
Male
Female
Email:
*
Phone:
*
Postal Code:
*
Preferred Method of Contact (select all that apply):
*
Phone
Email
Text
Next
How much coverage do you need? (select one):
*
Enter Amount
Not sure, contact me to determine
Amount:
Length of policy term (select all options of interest):
*
10 Years
20 Years
30 Years
Lifetime
Life Insurance requires both medical and financial underwriting. The following questions will allow us to provide a more accurate quote.If you prefer to answer these questions offline please call us at 972.663.5190 to speak to an advisor, or download a printable PDF and upload below or fax to 214.635.1099
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Height:
Weight:
Any tobacco use in the last 12 months?
Yes
No
Are you currently taking any medications?
Yes
No
Please list:
Any family history of cancer, diabetes or heart disease?
Yes
No
Please list:
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Webinar
Friend/Colleague
Online Search
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Banker
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Other
Other
*
Which one?
Who?
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Personal Home & Auto Quote Form
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Legal Name:
*
First
Middle
Last
Suffix:
Nickname (if applicable):
Email:
*
Phone:
*
Preferred Method of Contact (select all that apply):
*
Phone
Email
Text
Home Address:
*
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Next
Upload Current Policies
Click or drag files to this area to upload.
You can upload up to 6 files.
How would you prefer to provide additional information
Via this online form
Have an advisor contact me
Number of Drivers
Primary Driver Name:
First
Last
License Number:
Date of Birth:
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1920
Marital Status
Single
Married
Driver #2
2. Name:
First
Last
License Number:
Date of Birth:
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1920
Driver #3
3. Name:
First
Last
License Number:
Date of Birth:
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1920
Driver #4
4. Name:
First
Last
License Number:
Date of Birth:
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Estimated Replacement Cost of Home:
Year Home Built:
Year of last roof update or repair:
Year of last plumbing update or repair:
Jewelry Amount:
Fine Art Amount:
Do you own any of the following?
Collectibles other than Fine Art
Boat, Water Vehicle/s
Golf Cart
Antique Car
Motorcycle
Collectibles Description:
Have you had any claims in the past 5 years?
Yes
No
Claim Details:
Standard Homeowner's Policies Exclude Coverage for Losses Due to Flood & Earthquake:
Would you like a quote for flood insurance?
Yes
No
Would you like a quote for earthquake insurance?
Yes
No
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Practice Protector Quote Form
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Step
1
of 3
Requested Effective Date:
*
Doctor/Owner's Name(s):
*
Email:
*
Phone:
*
Preferred Method of Contact (select all that apply):
*
Phone
Email
Text
Company (Legal) Name:
*
Practice Name (DBA if applicable):
FEIN:
Date Business Established:
*
Physical Address:
*
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Mailing Address (if different):
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
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Business Owner's Policy:
Includes Property, Liability and other important coverage for a business owner
Do you own the building?
Yes
No
Are you the only occupant?
Yes
No
Estimated Replacement Cost of Building:
Square Feet Occupied:
*
Is this a condo unit?
Yes
No
Amount of coverage for Business Personal Property:
*
In a worst case scenario: what would it cost to replace all contents, equipment, finish out, furniture, etc.
Standard Business Owner's Policies Exclude Coverage for Losses Due to Floods & Earthquakes:
Would you like a quote for flood insurance?
Yes
No
Would you like a quote for earthquake insurance?
Yes
No
Worker's Compensation:
Number of Support Employees:
Number of Doctors on Staff (Including W2 & Contractor):
Annual Payroll, excluding owners/officers:
Payroll Frequency (for pay-as-you-go)
Weekly
Bi-Weekly
Semi-Monthly
Monthly
How often do you pay your employees?
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Other Coverage:
Do you pay for, or reimburse, associates for their malpractice?
Yes
No
Do you provide health insurance for your employees?
Yes
No
Does your business have a 401K or pension plan?
Yes
No
If you are too sick or hurt to work, do you have enough disability insurance to:
Keep your practice doors open?
Yes
No
Continue to make your loan payment(s)?
Yes
No
Do you own any vehicles in the name of the practice?
Yes
No
Year, Make & Model of Vehicle:
How did you hear about us?
Webinar
Friend/Colleague
Online Search
Financial Advisor
Banker
Social Media Post
Other
Other
*
Who?
Which one?
I'm also interested in:
Health Insurance
Payroll Services
Payment Processing
Personal Home & Auto Insurance
Professional Liability (Malpractice)
Entity Professional Liability (Malpractice)
Higher Limits for Data Breach / Cyber Liability
Higher Limits for Employment Practices Liability
Life Insurance
Additional information for my advisor:
Custom Captcha
*
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Professional Liability (Malpractice) Quote Form
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Step
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Legal Name:
*
First
Middle
Last
Suffix:
Nickname (if applicable):
Email:
*
Phone:
*
Preferred Method of Contact (select all that apply)
*
Phone
Email
Text
Specialty:
*
Select One
General Dentist
Oral Surgeon
Periodontist
Endodontist
Prosthodontist
Dental Radiologist
Pediatric Dentist
Orthodontist
Dental Pathologist
Dental Anesthesiologist
First 6 months of Practice?
*
Yes
No
Graduation Date:
Graduation Year:
Practice name:
Practice Zip Code (or City, State):
*
Practice County (if known):
Are you an owner?
Yes
No
Requested Effective Date:
*
Preferred Coverage Type
*
Claims Made
Occurrence
Not Sure
Is your practice limited to Endodontics?
Yes
No
Is your practice limited to Radiology?
Yes
No
Is your practice limited to Orthodontics?
Yes
No
Is your practice limited to Pathology?
Yes
No
Did you attend a formal residency program?
*
Yes
No
Select all the procedures you perform:
Placement of Implants
Extract Partially Impacted Teeth
Extract Soft Tissue Impacted Teeth
Extract Full Bony Impacted Teeth
Endo Multi-Rooted Teeth
Orthodontics
Therapeutic Botox
Cosmetic Botox
Dermo Fillers
Select all the procedures you perform:
Elective facial cosmetic surgery
Rhinoplasty
Rhytidectomy
Otoplasty
Blepharoplasty
Breast augmentation
Liposuction
Select all types of anesthesia you administer:
Local
Nitrous
Oral Sedation (single dose of anxiety drug combined with nitrous)
* Multiple Dose Oral Sedation (more than one dose of anxiety drug on day of procedure combined with Nitrous)
IV/IM Conscious Sedation
General Anesthesia
* Please note that a combination of drugs or cocktail given as a single dose in conjunction with nitrous is still single dose oral sedation.
Have you ever had a malpractice claim and/or state board sanction?
*
Yes
No
Do you currently have coverage?
*
Yes
No
Have you been practicing without Professional Liability (Malpractice) coverage for more than 20 days?
*
Yes
No
How long have you been practicing without Professional Liability (Malpractice) coverage?
*
Which coverage type do you currently have?
Claims Made Form
Occurrence Form
Not Sure
What is your retroactive date? (highlight year to change):
Current Carrier:
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Information for Discounts:
In the last 12 months, have you completed a risk management course?
Yes
No
Association Membership (select all that apply):
State Dental Association
ADA
AGD
AGD Master
AGD Fellow
Specialty Association
How did you hear about us?
Webinar
Friend/Colleague
Online Search
Financial Advisor
Banker
Social Media Post
Other
Other
*
Who?
Which one?
I'm also interested in:
Disability Insurance
Life Insurance
Health Insurance
Business Owner's Insurance
Home & Auto Insurance
Other information for my advisor:
Custom Captcha
*
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New Graduate Quote Form
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Step
1
of 2
Select Coverage to be Quoted (select all that apply):
Professional Liability (Malpractice) -
Coverage for your work with patients
Disability Income -
Protects your ability to continue to receive an income equal to your education and training in the event of an accident or illness
Legal Name:
*
First
Middle
Last
Suffix:
Nickname (if applicable):
Email:
*
Phone:
*
Preferred Method of Contact (select all that apply):
*
Phone
Email
Text
Specialty:
*
Select One
General Dentist
Oral Surgeon
Periodontist
Endodontist
Prosthodontist
Dental Radiologist
Pediatric Dentist
Orthodontist
Dental Pathologist
Dental Anesthesiologist
University / Program Attended:
*
Graduation Date:
*
Employer/Practice Name (if known):
Thinking of opening your own practice in the future?
Yes
No
Requested Effective Date:
*
Professional Liability (Malpractice): The following selections will impact the company we recommend & future pricing. It is best to select only the items you
know
you will be performing.
Select procedures you will perform:
Placement of Implants
Extract Partially Impacted Teeth
Extract Soft Tissue Impacted Teeth
Extract Full Bony Impacted Teeth
Endo Multi-Rooted Teeth
Orthodontics
Therapeutic Botox
Cosmetic Botox
Dermo Fillers
Select the procedures you will perform:
Elective facial cosmetic surgery
Rhinoplasty
Rhytidectomy
Otoplasty
Blepharoplasty
Breast Augmentation
Liposuction
Select all types of anesthesia you know you will administer:
Local
Nitrous
Oral Sedation (single dose of anxiety drug combined with nitrous)
* Multiple Dose Oral Sedation (multiple doses of anxiety drug with nitrous)
IV/IM Sedation
General Anesthesia
* Please note that a combination of drugs or cocktail given as a single dose in conjunction with nitrous is still single dose oral sedation.
Practice Zip Code (or City, State):
*
Form of coverage requested:
*
Claims Made
Occurrence
Not Sure
Disability Insurance: The following information will allow us to provide you with competitive quotes from several high quality carriers.
Date of Birth
*
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YYYY
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Gender:
*
Male
Female
Height:
Weight:
Are you currently taking any medications?
*
Yes
No
Please list:
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How did you hear about us?
Webinar
Friend/Colleague
Online Search
Financial Advisor
Banker
Social Media Post
Other
Other
*
Who?
Which one?
I'm Also Interested In (select all that apply:
Term Life Insurance
Health Insurance
Home/Renters & Auto Insurance
Additional information for my advisor:
Custom Captcha
*
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