Cyber Suite Liability Application | TDIC (The Dentists Insurance Company)
Cyber Suite Liability Application


M/DD/YYYY




Primary Practice Location
(The location where you spend the majority of your time practicing dentistry.)


















AUTHORIZATION

I authorize release and exchange of information between my past and present insurance carriers and The Dentists Insurance Company, involving past and future underwriting and claims matters. I have answered the questions on this application truthfully. I agree to notify The Dentists Insurance Company of any change in the information contained in the application—before and after a policy is issued—and to supply such further underwriting information as The Dentists Insurance Company may require. I further agree to be bound by the underwriting guidelines of The Dentists Insurance Company

Electronic Signature (required)

Please check the electronic signature button, type in your first and last name in the space provided, and click the button on this page labeled "Submit" to certify that all statements made in this application and its attachments are complete and accurate to the best of your knowledge, and to authorize TDIC to verify the information provided in this application and its attachments.


FRAUD WARNINGS

Arizona Applicants The last paragraph under Authorization is deleted and replaced with “If any insured has concealed or misrepresented any material fact or circumstance relating to this insurance at any time, such misrepresentations, omissions, concealment of facts and incorrect statements shall not prevent a recovery under this policy unless:

  1. Fraudulent.
  2. Material either to the acceptance of the risk, or to the hazard assumed by the insurer.
  3. The insurer in good faith would either not have issued a policy, or would not have issued a policy in as large an amount, or would not have provided coverage with respect to the hazard resulting in the loss, if the true facts had been made known to the insurer as required either by the application for the policy or otherwise.

Any other terms or conditions of the application and this policy notwithstanding, all statements and descriptions in the application for this policy, or in negotiations therefore, by or on behalf of the insured, shall be deemed to be representations and not warranties.

Illinois Applicants The last paragraph under Authorization is deleted and replaced with “No misrepresentation or false warranty made by the insured or in his behalf in the negotiation for a policy of insurance, or breach of a condition of such policy shall defeat or avoid the policy or prevent its attaching unless such misrepresentation, false warranty or condition shall have been stated in the policy or endorsement or rider attached thereto, or in the written application therefor. No such misrepresentation or false warranty shall defeat or avoid the policy unless it shall have been made with actual intent to deceive or materially affects either the acceptance of the risk or the hazard assumed by the company.

Minnesota Applicants The last paragraph under Authorization is deleted and replaced with “A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.”

Nevada Applicants Any other terms or conditions of the application and this policy notwithstanding, all statements and descriptions in the application for this policy, or in negotiations therefore, by or on behalf of the insured, are representations and not warranties.

New Jersey Applicants Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

Pennsylvania Applicants Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

By submitting your application, you certify that all statements made in this application and its attachments are complete and accurate, and you understand that falsification will disqualify your application.

Submit