Workers' Compensation Application | TDIC (The Dentists Insurance Company)
Application for Coverage
Workers' Compensation Insurance

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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.

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.


Policy Period (at 12:01 a.m., standard time)


What is this?


Contact and Other Professional Information





























Contact for Claims











Contact for Annual Payroll Audit










Payroll
Payroll - Primary Practice Location





Full-time is 30+ hours per week




What is this?


Workers' Compensation History


(if no prior coverage, indicate zero)
Loss History
Loss information for 4 years must be obtained from currently valued loss runs valued within 90 days of the requested effective date.


Entity Type


















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.

Any insurance issued in response to this application is void if an insured has concealed or misrepresented any material fact or circumstances relating to this insurance at any time prior to issuance or renewal of the policy.

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.