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First Name

Last Name

Facility or Practice Name

Select your county of practice

What best describes you?

Describe your dental specialty and scope of practice:

Policy Type

Retroactive Date

Have you always practiced within NY State?

Yes

No

Policy limits requested

Other policy limit requested

6-digit License Number

Please list the date you were first licensed in any state (active or expired)

Phone Number

Email Address

How would you like us to contact you?

Email

Phone

Best time to call

Are you an active member of NYSDA?

Yes

No

Do you perform the following procedures? (check all that apply)

Are you practicing:

Full time (20+ hours/wk)

Part time (<20 hours/wk)

Average number of patients — daily

Average number of patients — weekly