Applications, Supplemental Forms, and Related Questionnaires

Provided below is a list of applications and forms needed to initiate the quotation process for insurance products offered through TDC Specialty Underwriters. Each link provides access to a PDF version of the document in a writable form, which means the form can be completed on-screen. Once completed, print forms for signature.

After the forms have been signed and dated, scan the documents for inclusion with other required submission materials and e-mail them to: submissions@tdcspecialty.com

Or send them by regular mail to:

TDC Specialty Underwriters, Inc.
29 Mill Street
Unionville, CT 06085

Upon receipt of your submission, our Submissions Team will send you an e-mail confirmation to acknowledge receipt and advise you of any further actions you need to take to assure 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.

If you have any questions regarding these forms, please contact our Submissions Team at (860) 269-2810.

Complex Risks:

• Physician Group Complex Risks Professional Liability Insurance Application
• Physician ERP Application
• Health Care Organizations and Providers Liability Insurance Application

Cyber Insurance:

• Cyber Insurance for Healthcare Organizations Application

Excess:

• Umbrella Excess Liability Application

Life Sciences:

• Life Sciences Products-Completed Operations Liability Insurance Application

Long Term Care:

• Long Term Care Liability New Business Application
• Long Term Care Liability Insurance Renewal Questionnaire
• Long Term Care Liability Additional Location Supplement

Managed Care:

• Managed Care Errors and Omissions New Business 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)

Medical Facilities:

• Medical Facility Liability New Business Application
• Medical Facility Liability Renewal Application
• Medical Facility Liability ASC and Pain Management Supplemental
• Medical Facility and Providers Urgent Care and Walk-In Clinic New Business Application
• Medical Facilities Group Home Supplemental Application
• Medical Facilities Adult Daycare Supplemental Application
• Medical Facilities Ambulatory Surgery Center Supplemental Application
• Allied Medical Ambulance—EMT Transport Supplemental Application
• Medical Facilities Outpatient Counselors & Counseling Supplemental Application
• Medical Facilities Home Health Care—Medical Staffing Agency—Hospital Supplemental Application

Non-Standard Physicians:

• Allied Personnel Professional Liability Insurance Application
• Dentists & Oral Surgeons Professional Liability Insurance New Business Application
• Locum Tenens Application
• Physicians Professional Liability Insurance New Business Application
• Podiatry Professional Liability Policy New Business Application
• Professional Liability Policy Renewal Application
• Insured Request for Advancement of Retroactive Date
• No Known Claims or Losses Declaration
• Bariatric Surgery Procedure Questionnaire
• LVR Surgery Procedure Questionnaire
• Neurosurgery Questionnaire
• Pain Management Procedure Questionnaire
• Plastic and Cosmetic Procedure Questionnaire
• Prior Acts Coverage Supplemental Questionnaire & Warranty Statement
• Procedure Questionnaire
• Claims Information Form

Additional:

• Hired Non-Owned Auto Supplement