Professional Liability Application for Experienced Dentists | TDIC (The Dentists Insurance Company)
Application for Claims-Made Coverage*
Professional & Dental Business Liability Insurance

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* A policy providing coverage for claims made during the policy period.  If the policy has a retroactive date, a loss which occurred before that date is not covered.

* indicates a required field

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 Professional & Dental Business Liability 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?


What is this?

1.     CONTACT AND OTHER PROFESSIONAL INFORMATION









M/DD/YYYY
Primary Practice Location
(where you practice the majority of the time)









































 

2.     TYPE OF PRACTICE






















3.     STATE DENTAL ASSOCIATION OR SOCIETY






4. Please provide the name(s) of your professional liability carrier(s) for the past five years, including policy period and type of policy. (All information must be provided, not just a copy of your current policy declarations.)




















7.  Do you treat patients under any of the anesthetic modalities listed below? (please check all that apply) *














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EXCLUSION

Any policy issued in response to this application will exclude liability arising out of any allegation, claim or incident you are required to but did not disclose in response to Questions 18 and 19 above.

Employment Practices Liability Insurance (Optional Coverage)


What is this?

AUTHORIZATION

I authorize release and exchange of information between my past and present dental society, the state dental association or society and their insurance consultants, any hospital where I presently hold or previously held staff privileges, prior professional liability insurance carriers and their agents, previous attorneys of record in any liability actions or claims, any government agency, and The Dentists Insurance Company (TDIC) involving past or future underwriting and claims matters. I hereby represent and warrant the truth of my statements and representations made herein, and that I have not withheld any information that is reasonably likely to influence the judgment of the company in considering this application for professional & business liability insurance and/or employment practices liability insurance. 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 agree to notify TDIC of any change in the information contained in this application -- before and after a policy is issued -- and to supply such further underwriting information as TDIC may require.

I hereby certify that I have reported to my present or previous insurance carriers all known claims and all incidents which I have reason to believe could give rise to future claims, and have disclosed all such information in this application.

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.

           

FRAUD WARNINGS

Alaska 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.

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.

Hawaii Professional & Dental Business Liability Application Warranties, misrepresentations in applications. All statements or descriptions in any application for an insurance policy or in negotiations therefor, by or on behalf of the insured, shall be deemed to be representations and not warranties. A misrepresentation shall not prevent a recovery on the policy unless made with actual intent to deceive or unless it materially affects either the acceptance of the risk or the hazard assumed by the insurer.

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 & Dental 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 & Dental 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.