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Workers’ Compensation
Quote Request

Request your free, no-obligation Workers’ Compensation quote now. Your request will be sent to your dedicated agent for review and they will contact you to discuss.

1Practice Info
2Employees & Underwriting

Contact Information

First name is required.
Last name is required.
Contact number is required.
A valid email address is required.

Practice Details

Effective date is required (e.g. 04/05/2025).

Physical Address to Be Insured

Street address is required.
City is required.
State is required.
ZIP code is required.

Is there a 2nd location? (optional)

Any Workers’ Compensation losses in the last three years? (optional)

* Required fields
Please fill in all required fields above.

Employee & Payroll Information

Enter the number of full-time and part-time employees and payroll. Full-time is equal to 30+ hours per week. Payroll for included owners and officers cannot exceed 25% of total payroll.

Please enter a number.
Please enter a number.
Annual payroll is required.

Underwriting Questions

Do you operate a mobile dental facility?
Have you offered Workers’ Compensation coverage through a Professional Employer Organization (PEO) during the last two years?
Are you going to be affiliated with an Employee Leasing firm or a Professional Employer Organization (PEO) during the coverage period requested?
Are there any employees under age 16?
Does the employer own, operate or lease an aircraft or watercraft for business purposes?
In the last three years, has the employer had their Workers’ Compensation coverage canceled for non-payment of premium, had a lapse in coverage, or been operating with employees without Workers’ Compensation coverage in force?
Does the employer engage in, or own, any other businesses?
Is there a written formal safety program in place?
Has the employer, or its owners or officers, filed for bankruptcy within the last five years?
Are you aware of any incident which could give rise to a claim in the future?

Please note: the information upon which quotes are based is on the information you have provided. As this information could be subject to error, Insurance by Dentists cannot guarantee the correctness of the rates quoted.

This form is for proposal use only. An application is required for coverage, subject to underwriting review and approval.

Please fill in all required fields above.

Quote Request Submitted

Thank you — your dedicated agent will review your information and be in touch shortly to discuss your coverage options.