Sample Forms | TDIC (The Dentists Insurance Company)

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Take advantage of our sample documents — such as allergy warnings, health history and letters — by using them in your dental office.

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Allergy Warning Labels Content Type - Sample Form, State, Alaska, Arizona, California, Hawaii, Illinois, Minnesota, Nevada, New Jersey, North Dakota, Pennsylvania

Authorization for Agent to Consent to Dental Treatment of a Minor Content Type - Sample Form, State, Alaska

Authorization for Agent to Consent to Dental Treatment of a Minor Content Type - Sample Form, State, Arizona

Authorization for Agent to Consent to Dental Treatment of a Minor Content Type - Sample Form, State, California

Authorization for Agent to Consent to Dental Treatment of a Minor Content Type - Sample Form, State, New Jersey

Authorization for Agent to Consent to Dental Treatment of a Minor Content Type - Sample Form, State, Pennsylvania

Authorization for Care-taker to Accompany a Minor Content Type - Sample Form, State, Alaska, Arizona, California, Hawaii, Illinois, Minnesota, Nevada, New Jersey, North Dakota, Pennsylvania

Authorization for Release of Dental Records Content Type - Sample Form, State, Alaska

Authorization for Release of Dental Records Content Type - Sample Form, State, Arizona

Authorization for Release of Dental Records Content Type - Sample Form, State, California

Authorization for Release of Dental Records Content Type - Sample Form, State, Hawaii

Authorization for Release of Dental Records Content Type - Sample Form, State, Illinois

Authorization for Release of Dental Records Content Type - Sample Form, State, Minnesota

Authorization for Release of Dental Records Content Type - Sample Form, State, Nevada

Authorization for Release of Dental Records Content Type - Sample Form, State, New Jersey

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The Dentists Insurance Company
1201 K Street, 17th Floor
Sacramento, CA 95814

(800) 733-0633

CA Insurance Lic. #0652783

This company was issued a secure rating by the A.M. Best Company, click for additional details

The Dentists Insurance Company underwrites Professional Liability in AK, AZ, CA, HI, ID, IL, MN, MT, NV, NJ, ND, OR, PA, TN, WA, as well as Commercial property and GL in OR, WA, ID, TN & MT. Additional coverages written by TDIC include: Commercial Property and Cyber Suite Liability in AZ, CA, HI, IL, MN, NV, NJ, ND and PA. TDIC also underwrites Workers’ Compensation in CA. Other insurance products are placed through TDIC Insurance Solutions or other brokers with outside carriers, or with WDIA, a full service brokerage that places disability, health, life, long-term care, cyber security and other coverages in Washington, or IDIA, a full service brokerage that places workers’ comp, disability, health, life, long-term care and other coverages in Idaho with outside carriers.

800.733.0634

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