First Name

Last Name

Email

Phone Number

I am a:

• Dentist
• Staff/Family
• Student
• Other... This choice will expand a text box

Preferred method of initial contact:

• Email
• Phone

Insurance for the Practice:

• Professional Liability (Malpractice)
• Business Owners (General Liability, Building, Contents)
• Data Breach (Cyber-liability)
• Employers Practice Liability
• Entity Professional Liability
• Workers Compensation
• Renovation/Builders Risk Coverage
• Umbrella Insurance (Commercial)
• Umbrella Insurance (Personal)

Health & Life Insurance:

• Disability Insurance (Individual)
• Disability Insurance (Group)
• Life Insurance (Individual)
• Life Insurance (Group)
• Health Insurance (Individual)
• Health Insurance (Group)
• Short Term Medical
• Medicare Plans
• Vision Insurance
• Business Overhead Expense
• Cafeteria Plans
• ERISA/HIPAA (compliance for your employee benefits)
• AFLAC products (Accident, Cancer, Disability, Critical Illness, Vision, Hospital Confinement)
• Health Reimbursement Arrangement

Retirement Planning:

• Retirement Plans
• ERISA Bond
• Professional Alliance Investing
• Long Term Care

Additional Comments/Questions

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