Dental Clinic Insurance Quote

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Policy Timing

Coverage start, expiration, or takeover date

Effective / Start Date * Reason for This Date * Select one... New practice / opening date Current policy expiration date Practice acquisition / takeover date Mid-term switch Other Current Policy Expiration Date (if renewing or switching) Do You Own or Lease This Building? *

Reason for This Date

Current Policy Expiration Date (if renewing or switching)

Do You Own or Lease This Building?

Own Lease

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Practice Identity

Legal name, DBA, EIN, and entity type

Corporation / Legal Name * DBA (if different) EIN # * Legal Entity Type * Select... Sole Proprietorship Partnership LLC Professional Corporation (PC) S-Corporation C-Corporation Other Year Business Started at This Location * 📍 Property & Mailing AddressesWhere the clinic is located and where to send correspondence Clinic / Property Address Street Address * City * State * Select... WashingtonOregonIdaho NevadaArkansasSouth Dakota PennsylvaniaTexasIndiana Other ZIP Code * County Inside or Outside City Limits? *

DBA (if different)

EIN #

Legal Entity Type

Year Business Started at This Location

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Property & Mailing Addresses

Where the clinic is located and where to send correspondence

Clinic / Property Address

Street Address

City

State

ZIP Code

County

Inside or Outside City Limits?

Inside city limits Outside city limits

Fire District Mailing Address (if different from above) Mailing Street Address City State ZIP 👤 Owner / Contact InformationWho should the broker contact? Owner's Full Name * Owner's Cell Phone * Owner's Fax # Owner's Email Address * Hours of Operation * 🏗️ Building DetailsConstruction, size, renovation history, and safety systems Year Building Was Built * Building Construction Type *

Mailing Address (if different from above)

Mailing Street Address

City

State

ZIP

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Owner / Contact Information

Who should the broker contact?

Owner's Full Name

Owner's Cell Phone

Owner's Fax #

Owner's Email Address

Hours of Operation

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Building Details

Construction, size, renovation history, and safety systems

Year Building Was Built

Wood Brick Metal Mixed

Number of Stories * Select... 1 story2 stories 3 stories4+ stories Is There a Basement? *

Yes No

Clinic Building Sq Ft * Total Property Area Sq Ft (building + parking) * Renovation History — Most Recent Year for Each System Plumbing Updated Wiring Updated Heating Updated Roof Updated Safety Systems Fire Sprinkler System Installed? *

Total Property Area Sq Ft (building + parking)

Renovation History — Most Recent Year for Each System

Plumbing Updated

Wiring Updated

Heating Updated

Roof Updated

Safety Systems

Fire Sprinkler System Installed?

Yes — installed and working No Partial coverage only

Alarm System Type *

Central Station — With Keys Central Station — Without Keys Local Gong Police Connect None

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Values & Financials

Building, contents, payroll, and annual sales

Contents: Include dental equipment (chairs, X-ray units, sterilizers, computers, instruments), furniture, and anything else you own that is not permanently attached to the building and could be moved out.

Estimated Value of the Building (replacement cost — if you own it) Estimated Value of Contents (equipment, instruments, furniture — everything movable) * Number of Full-Time Employees * Number of Part-Time Employees * Total Annual Payroll (all employees) * Select range... Under $100,000 $100,000 – $250,000 $250,000 – $500,000 $500,000 – $1,000,000 $1,000,000 – $2,500,000 Over $2,500,000 Total Annual Gross Sales / Receipts * Select range... Under $250,000 $250,000 – $500,000 $500,000 – $1,000,000 $1,000,000 – $2,500,000 $2,500,000 – $5,000,000 $5,000,000 – $10,000,000 Over $10,000,000 📋 Current Insurance & Claims HistoryExisting coverage and any prior losses Current Insurance Company Current Policy Number Any Claims in the Last 5 Years? *

Estimated Value of Contents (equipment, instruments, furniture — everything movable)

Number of Full-Time Employees

Number of Part-Time Employees

Total Annual Payroll (all employees)

Total Annual Gross Sales / Receipts

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Current Insurance & Claims History

Existing coverage and any prior losses

Current Insurance Company

Current Policy Number

Any Claims in the Last 5 Years?

No claims Yes — I'll describe below

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Lien Holders (Optional)

Banks or lenders with a financial interest in the building or equipment

Lien holder: Any bank, lender, or financing company that holds a mortgage or loan secured against this property or major equipment. They must be listed on the policy.

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Certificate Holders (Optional)

Landlords, property managers, or other parties that need to be listed on your certificate of insurance

Certificate holder: Any party (typically your landlord or a government entity) that requires proof of insurance. Add one entry per certificate holder needed.

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Upload Documents (Optional)

Attach your current dec pages and/or loss runs to speed up quoting

Why upload? Attaching your current declarations page and loss run history allows us to return a more accurate quote faster — and compare your existing coverage side-by-side with new options. Both documents are optional but helpful.

Current Dec Page(s)

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Declarations Page

Your current policy's first page showing coverage limits, carrier, and policy period

PDF JPG PNG DOC

Loss Runs

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Loss Run Report

Claims history from your current or prior carrier — typically 3–5 years

PDF XLS JPG DOC

Max 10 MB per file · Files are transmitted securely · You can also email documents directly to CommercialInsuranceAgency@gmail.com