Lessor's Risk Commercial Property Application | TDIC (The Dentists Insurance Company)
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Application for Coverage
Commercial Property
Lessor's Risk (Building Owners Policy)

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Terms & Conditions

By agreeing to these terms and conditions, I acknowledge that I am consenting to conduct an insurance transaction electronically with The Dentists Insurance Company, “TDIC”. I understand that any insurance contract or other form resulting from this electronic transaction with TDIC will not be denied legal effect, validity or enforceability solely because it was conducted all, or in part, in electronic form.

Please read this before filling out your application for Commercial Property (Building Owners) insurance.
You warrant and represent that the following statements are yours and that you know the statements to be true. You know and intend that we will rely on the truth of the information you have provided in deciding to issue a policy to you, and that providing any false information in this application is grounds for us to deny you insurance.




What is this?










Name insured (List all owners):











Property Location Address:





















2. Insured Location Building Information























Alarm and protection systems:




3. Amount of Coverage Needed










4. Insurance History


5. Claims/Loss History




What is this?
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. SIGNING THIS APPLICATION DOES NOT BIND THE APPLICANT OR THE INSURER TO COMPLETE THE INSURANCE CONTRACT. HOWEVER, IF A POLICY IS ISSUED, THIS APPLICATION WILL BECOME PART OF THE POLICY.

I understand the importance of requesting sufficient insurance equal to 100 percent of the replacement value of my property. If I have not requested sufficient coverage, I understand a loss I might have may affect my future insurability.

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.




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.

           

FRAUD WARNINGS

Arizona Professional & Dental Business Liability Application 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.

Nevada Professional & Dental Business Liability Application 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 Professional & Business Liability Application Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

Pennsylvania Professional & Business Liability Application 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.

800.733.0633
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