Workers’ Compensation Quick Quote Form – Dentists

  • 1. 8810: Clercial and/or Office Employees:

  • Gross annual payroll for clerical/office employees:
  • 2. 8832: Dental Assistants, Hygienists, and Employee Dentists

    (Not including corporate officers or partners)
  • Gross annual payroll for assistants/hygienists etc:
  • 3. Corporate Officers or Partners

    (Sole proprietors not eligible)
  • 4. Will the individuals named in #3 be included or excluded under the policy?*

  • 5. 9915: Janitorial , Maintenance or Custodial

    (if any)
  • Gross annual payroll for janitorial employees:
  • Current Carrier

  • This field is for validation purposes and should be left unchanged.

This is not an offer to sell insurance. Insurance coverage cannot be bound or changed via submission of this online form. Note that any proposal of insurance we may present to you will be based upon the values developed and exposures to loss disclosed to us on this online form and/or in communications with us. All coverage is subject to the terms, conditions and exclusions of the actual policy issued.