HUH Professional Liability Insurance

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Dental Professional Liability Insurance Pre-Application

Dentist Name
Contact person
Address
City
State		Zip Code
Phone	( )
Fax	( )
E-mail
Current Policy Effective Date		Expiration Date
Occurrence		Claims-Made
Retroactive Date
Current limits of Liability
Number of Years in Practice
Specialty / Type of Practice
Incorporated?	Yes	No
Separate Limits for Corporation	Yes	No
How many locations outside Kentucky?
	In what States?
What Percentage of Practice (revenue-wise) do these locations represent?
	Number of Hours
Claim History (please provide complete details including any payment amount)