FB Malpractice Quote form - Powered by Keap

Professional Liability/Malpractice

Quote Form

* In an effort to gather quotes with the appropriate carrier(s), Please answer the following questions below. If you don't know the answer to a question, simply state "I don't know". If the question does not apply, please put a "N/A" in the field. Thank you!

First Name *

Last Name *

Cell Phone

Email *

Which State do you work in?

Are you moving to another state soon? If so, which state and when?

Occupation *

Job Title/Specialty

Business Owner *

YesNo

If you are a Business Owner, please complete the following. If you are not a business owner, skip this section.

What's the legal name of your entity (meaning the legal name of your LLC, S-Corp, C-Corp, etc.)?

How is this entity filed with the IRS?

Is this entity covered under your Malpractice Policy?

YES, I have "shared limits" between my entity and personal coverageYES, I have "separate limits" between my entity and personal coverageNO, I do not have my entity coveredI have no idea if my entity is covered

Do you have any partners?

Yes, my partner is another dentist/doctorYes, my partner is a non-dentist/doctorNo, I am the sole owner

If YES, how are your Partners covered?

They have their own separate policy We are all covered on a group plan together

Do you share, lease or own office space w/ another doc?

YesNo

Do you have any dentists/doctors you employ or who come into your office for ANY REASON who perform ANY Services for your practice or corporation?

YesNo

Are all of those dentists/doctors listed on your entity for "Vicarious Liability"?

YESNOI DO NOT KNOW

If you are a Dentist, do you have any Hygienists that you employ? If so, how many?

Do your Hygienists have a Malpractice Policy in place?

YES, They have their own coverageYES, I provide coverage on our group planNO, they do not have coverageI am not sure

Who is your current Malpractice carrier?

What type of policy do you have?

OccuranceClaims Made

What are your current policy limits?

Are you currently covered by an Individual Policy, or are you covered by a Group Policy through your empolyer?

If your Current Policy is a Group Policy through your employer, who is your employer?

Do you have Any Current or Past Claims? If Yes, please provide details regarding the claim(s). Please include the following: Date, if It's still open/closed/discharged, and the payout amount

When does your Current Policy renew?

What is your reason for shopping for new coverage? (i.e. Losing coverage, want to find a more competitive premium, current carrier is not covering the procedures I am pursuing, etc.)

When is the requested effective date of this policy?

Please list the malpractice carriers you have had over the last 6 years. Please list the carrier name and the date range you had them in place. If you have not been practicing for 6 years, please list the years you have had coverage

Once we have this information, we will be able to determine which carriers are best to pursue for coverage as well as when we are able to apply for that coverage. Please submit your form by clicking the button below and our team will be in touch with you here shortly. Thank you!

Consent and Authorization for Communication

To allow our agency the ability to provide your requested quote and to effectively schedule an appointment(s) to review that quote, we need to get your authorization to allow The Firebird Agency, LLC and our staff to communicate with you by means of emails, phone calls, and SMS text messages.

By clicking the checkbox below and providing your email and phone number, you consent and agree to receive messages by those means from The Firebird Agency, its agents, and staff. Your authorization is allowing The Firebird Agency, their agents, and staff to also use SMS text messages to effectively communicate with you regarding our programs, offers, marketing, and other information that may be of interest to you. You also understand that you do not have to agree to receive autodialed or prerecorded calls or texts in order to use and enjoy the products and services offered by The Firebird Agency, LLC. You may decline to receive autodialed or prerecorded calls or texts to your mobile phone number in several ways, including by responding with STOP or by emailing the request to opt out with the mobile number, to [email protected] Your carrier's standard messaging and data rates may apply.

To move forward with working with our Firebird team, please give your authorization below. Then click the red submit button.

I give my consent and authorization for all communication (phone, email, & SMS text messaging) from The Firebird Agency, LLC and their staff. *