Practice Insurance Quote Form
Your Details
Full name: (incl Title)
*
Contact telephone number:
*
Email address:
*
Practice Details
Name of practice: (legal entity)
*
Practice address:
*
Postcode:
*
Practice type:
*
Please select
Dentist
Prosthetist
Dental Laboratory
Orthodontist
Dental Surgeon
Construction - Walls
*
Please select
Brick
Concrete
Fibro
Wood
Other
Construction - Floor
*
Please select
Concrete
Wood
Other
Construction - Roof
*
Please select
Tile
Metal
Other
Age of building:
*
Security (select all applicable)
*
Deadlocks on doors
Local alarm
Monitored alarm
Insurance Requirements
Buildings sum insured
Contents (including stock) sum insured
Gross revenue sum insured
Public Liability cover required
Please select
$20 million
$10 million
$5 million
Glass cover Required
Yes
No
Money cover Required
Please select
$1,000
$2,000
$5,000
Cover for mobile phones or laptops (away from your practice)
Machinery or electronic breakdown Required
Yes
No
Do you required breakdown cover for any dental equipment valued at over $25,000
Please provide full details of any claims made and/or losses suffered under previous Practice Insurance during the past 5 years (whether or not a claim was made):
*
If none, please state
Please use this box to provide any further information that may be relevant to your Practice Insurance policy :
Current Practice Insurance provider:
*
If none, please state
Current Practice Insurance premium:
*
If none, please state
Renewal date of existing insurance/date cover to start (as applicable):
*
NB: Cover is not in force until agreed upon by the company
Contacting You
Are you an existing Dental Essentials customer?
*
yes
no
Preferred contact method:
*
Please select
Telephone
Email
Letter
Preferred contact time:
Please select
No preference
08:00-10:00
10:00-12:00
12:00-14:00
14:00-16:00
16:00-18:00
How did you hear about us?
*
Please select
Referred by friend
Referred by another business
Referred by another website
Search engine
Advertising
Dental Essentials is a trading name of Bourchier Nominees Pty Ltd. We would like to contact you from time to time about products and services (or with news, offers and promotions) that we feel may be of interest to you. By providing us with your contact details, you consent to being contacted by these methods for these purposes.
Please tick the box if you prefer to
not
to receive marketing communications from us by post or telephone.
Please tick the box if you prefer to
not
receive marketing communications from us by email, text messaging or other electronic means.