Dds4dds 2025

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The document is an application form for professional liability insurance from OMS National Insurance Company, RRG, specifically designed for new business entities such as corporations or partnerships. It outlines the necessary information required from applicants, including entity details, coverage information, office locations, claims history, and operational details. The application emphasizes the importance of complete and accurate responses and includes a privacy notice regarding the handling of protected health information.

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Click ‘Get Form’ to open the dds4dds application in the editor.
Begin by filling out the ENTITY INFORMATION section. Enter the Legal Name of Entity, Mailing Address, and Owner(s)/Partner(s) names. Ensure all fields are completed accurately.
Proceed to the COVERAGE INFORMATION section. Select your requested effective date and limits of coverage. Be sure to mark your choices clearly.
In the OFFICE LOCATIONS section, list all current practice locations along with their Facility Codes. Use additional sheets if necessary for more locations.
Complete the ENTITY OPERATIONS section by providing census information for each affiliated Oral & Maxillofacial Surgeon/Dental Specialist and any relevant details about your operations.
Finally, review all sections for completeness and accuracy before signing and dating the application at the end.

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