Applications, Supplemental Forms, and Related Questionnaires
Below are the applications and forms needed to initiate the quotation process for insurance products offered through TDC Specialty Underwriters. Each link opens a fillable PDF, which means the form can be completed on-screen. Once completed, print the forms, sign and date them, and include any additional required materials before emailing the submissions package.
How to Submit
Send completed application materials via email.
Or regular mail:
TDC Specialty Underwriters, Inc.
29 Mill Street
Unionville, CT 06085
Questions?
Our Submissions Team will send you an email confirmation to acknowledge receipt and advise you of any further action you need to take to ensure we have designated you as the broker of record on a respective submission. Our goal is to respond within one business day of receipt.
Please keep in mind that, at a minimum, completed forms must be accompanied by loss and exposure information related to a respective submission in order to be deemed complete and eligible for broker of record status.
Hospitals
Long Term Care
- Long Term Care Liability New Business Application
- Long Term Care Liability Insurance Renewal Questionnaire
- Long Term Care Liability Additional Location Supplement
Medical Facilities
- Medical Facility Liability New Business Application
- Medical Facility Liability Renewal Application
- Medical Facility Liability ASC and Pain Management Supplemental Application
- Medical Facility and Providers Urgent Care and Walk-In Clinic New Business Application
- Allied Medical Ambulance—EMT Transport Supplemental Application
- Medical Facilities Adult Daycare Supplemental Application
- Medical Facilities Ambulatory Surgery Center Supplemental Application
- Medical Facilities Durable Medical Equipment Supplemental Application
- Medical Facilities Group Home Supplemental Application
- Medical Facilities Home Healthcare—Medical Staffing Agency—Hospice Supplemental Application
- Medical Facilities Ketamine Supplemental Application
- Medical Facilities Medical Laboratory Supplement Application
- Medical Facilities Outpatient Counselors and Counseling Supplemental Application
- Medical Facilities and Providers Pharmacy Supplemental Application
- Medical Facilities and Providers Physician Supplemental Application
- Medical Facilities Schools Supplemental Application
- Medical Facilities Substance Abuse Addiction Treatment Supplemental Application
- Medical Facilities Telemedicine Supplemental Application
E&S Physicians
- Physician Group Complex Risks Professional Liability Insurance Application
- Physician ERP Application
- Physicians Professional Liability Insurance New Business Application
- Podiatry Professional Liability Policy New Business Application
- Dentists and Oral Surgeons Professional Liability Insurance New Business Application
- Professional Liability Policy Renewal Application
- Allied Personnel Professional Liability Insurance Application
- Bariatric Surgery Procedure Questionnaire
- Claims Information Form
- Insured Request for Advancement of Retroactive Date
- Locum Tenens Application
- LVR Surgery Procedure Questionnaire
- Neurosurgery Questionnaire
- No Known Claims or Losses Declaration
- Pain Management Procedure Questionnaire
- Plastic and Cosmetic Procedure Questionnaire
- Prior Acts Coverage Supplemental Questionnaire and Warranty Statement
- Procedure Questionnaire
Managed Care
- Managed Care Errors & Omissions Liability Exposure Update Questionnaire
- Managed Care Errors and Omissions New Business Application
- Managed Care Errors and Omissions Renewal Application
- Plan Purchaser Errors and Omissions Liability Application
Management Liability
- Healthcare Organizations Management Liability Insurance Application (To be used only for California, Utah, and District of Columbia)
- Healthcare Organizations Management Liability Insurance Application (To be used for all other states)
- Healthcare Organizations Management Liability Insurance Renewal Application