Insurance and Financial Services
for the Dental Profession

To discover the benefits of insuring your practice through BDA Plus, simply complete the brief details below and we will contact you with a quotation.

You

Salutation *	Please Select Mr Mrs Ms Miss Dr
Forename *
Surname *
BDA Member *	Please Select Yes No
Practice Address *
Practice Postcode *
Telephone *
Email Address
Mobile
Full Legal Status *	Please select Sole Trader Partnership Ltd Company
Number of years trading *	Please select 1 2 3 4 4+
What prompted you to visit our website? *	Please select BDA Conference BDA News BDA News Insert Steamline dedupe The Dentist Magazine Mailing - Brand Mailing Mailing - Prospect Mailing - Membership Insert Google BDA Website PR Activities Word of mouth

The premises

No of premises to be insured *	Please select 1 2 3 4 5 6 7 8 9 10 10+
No of Surgeries within premises *	Please select 1 2 3 4 5 6 7 8 9 10
Is terrorism cover required? *	Please select Yes No
Premises of standard construction (Brick/stone wall & tile/slate roof) *	Please select Yes No
Is the building occupied by you as a dental surgery? *	Please select Yes No
If no, please give details
Is the building free from flood, heave, landslide and subsidence *	Please select Yes No

General Information

Renewal Date *
Current Premium
Existing provider

Security

Are the premises protected by Alarm *	Please select Yes No
Name of Alarm company *
Alarm signal method *	Please select Bells only BT Redcare Other
Is there a police response *	Please select 1 2 3 None
Do local authority CCTV cameras cover the premises *	Please select Yes No
Are there any enhanced security measures *

Sums Insured

Contents (excl computers) *
Of which, how much is fixed equipment *
Computer Equipment *
Buildings sum insured (rebuild costs)
Tenant's improvements
Loss of rent payable (Annual figure)
Loss of rent payable indemnity period	12 months 18 months 24 months

Loss of Gross Fees / Business Interruption

Annual Practice Income (inc rent receivable) *
Indemnity Period *	Please select 12 months 18 months 24 months

Claims

Have you suffered any claims in the last 5 years *	Please select Yes No
If yes, please give details of dates, incident and costs

*Denotes compulsory field

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