Dentist's Advantage Change of Address

You can use this secure form to change, add, or delete an address listed on your policy. First, you'll select which address related to your practice is changing. Then, simply indicate the old address and new address (if you're adding or deleting a location, you can leave the "old address" or the "new address" blank, respectively).

Once you submit the information, you should receive confirmation within two to three weeks.

Please note that a change of address may have an impact on your policy's annual premium. If a change of address does change your premium, we will contact you directly to ensure that the appropriate adjustments are made and so that your practice continues to be insured accurately.

*Required field

*Type of Change:

	Change Primary Practice Location
	Change Mailing Address
	Change Primary Practice Location and Mailing Address
	Change to Additional Location
	Add an Additional Location (supply new address only)
	Remove an Additional Location (supply old address only)
Policy Number:

Old Address

Name:

Practice/Group name:

Address 1:

Address 2:

City:

County:

State:

Zip:

Phone number:

( ) -

Fax number:

( ) -

Email Address:

New Address

Name:

Practice/Group name:

Address 1:

Address 2:

City:

County:

State:

Zip:

Phone number:

( ) -

Fax number:

( ) -

Email Address:

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