Dentists Professional Liability Trust of Colorado

Application for Coverage

Dear Doctor:

Following are links to an application for the Dentists Professional Liability Trust of Colorado and related documents, which include a Supplemental Application, an Application for Retroactive Coverage, a Participation Agreement, a Trust Agreement, a HIPAA Business Associate Contract, and endorsement applications for both phases of implants.

This policy provides two million dollars of dental professional liability coverage, with a six million dollar aggregate. This coverage is only offered to the dentist who is (or becomes) a member of the Colorado Dental Association. This policy does NOT insure your office equipment, premises liability etc. These policies need to be purchased separately. Please contact our office for more information about these policies.

Retroactive coverage is available for dentists who have had claims-made polices in the past, with the dental practice being in the state of Colorado. Complete this page also to decline retroactive coverage.

The premium for this policy is determined by whether or not you do the surgical phase of implants or need retroactive coverage. Please call me for the premium applicable to your situation. The Trust offers three different premium payment options: you can pay the premium in full; pay the premium in three installments with a $50 administrative fee applied to the first payment; or you can have the premium deducted from your checking account on a monthly basis.

Thank you for your interest in Dentists Professional Liability Trust of Colorado. If you have any questions regarding the coverage provided, payment plans, or need assistance in completing the application, please do not hesitate to call.

Randy L. Kluender, DDS, MS

Information you need to know before completing the application.
  1. To apply for professional liability coverage through Dentists Professional Liability Trust of Colorado, you must be a member of the Colorado Dental Association or have an application for membership pending.
  2. To maintain your coverage you must remain a member of the Colorado Dental Association.
  3. We appreciate your efforts in accurately completing the application. Despite the length and scope, it is essential that we obtain adequate information so that underwriting can be completed.
  4. It is essential that all statements be completed and questions answered. Failure to complete appropriately may delay or prevent the underwriting of your application. Your signature is also required. If additional space is needed, use the appropriate section where applicable. One or more Supplemental Application forms must be completed and signed to report any Peer Review, State Board or malpractice claims.
  5. We urge you to complete your application immediately to allow adequate time for underwriting.
  6. A copy of your stationery, business card, yellow page listing or business advertisement and any other promotional material must be submitted along with the application.
  7. If you are a dentist contracting with a third party or a health care facility, you must submit a copy of all contracts with your application.
  8. When the application is completed and all documents gathered, please mail to the address below.
    (Adobe Acrobat reader is required to view/print these documents):
    Download ENTIRE packet at once (Size 637 KB)ORDownload EACH FORM individually (All must be completed)
    1. Application for Professional Liability Coverage
      • Pages 1-5: Application for Professional Liability Coverage
      • Page 2: Offices where you Practice
      • Page 2: Agreement to join the Colorado Dental Association
      • Page 3: Application for Retroactive Coverage
      • Page 6: Supplemental Application (for expanded answers to questions 16, 21, 22)
        • Complete multiple pages if you have multiple prior events
        • Indicate NONE if no prior claims
        • Sign and Date to complete application
    2. Participation Agreement
      • Terms of Participation in the Dentists Professional Liability Trust
      • Read, sign, and return with application
    3. HIPAA Business Association Agreement
      • Read, sign, and return with application
    Download those of the following ADDITIONAL APPLICATIONS as appropriate for the nature of your practice.
    Download, print and retain a copy for your records (BUT DO NOT MAIL TO US)
    Also, for your information, an article from the March/April 1987 edition of the Journal of the Colorado Dental Association regarding the formation of the Dentists Professional Liability Trust.
    Mail completed application and related supporting documents to:
    c/o Berkley Risk
    7807 E. Peakview Ave
    Suite 350
    Centennial, CO 80111

If you have questions concerning the completion of this application or questions about the Trust, please call 303-357-2613 or toll free 877-502-0113 or click HERE to send us a message. Our fax number is 866-699-1559.

NOTE: Coverage is only available through The Trust in Colorado. Should you have a practice with a satellite office outside of Colorado, the Trust cannot cover the satellite office. Please contact us with any questions you may have.

Policy rates are based on a five year progression with rates leveling out at the fifth year. There are discounts for new graduates. Please contact us for specific rates.