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. 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.
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 and
Health Systems
Long Term
Care
Medical
Facilities
E&S
Physicians
Reproductive
Health
Managed
Care
Management
Liability
Life
Sciences
- Medical Facility Liability New Business Application
- Medical Facility Liability Renewal Application
- Adult Daycare Supplemental Application
- Ambulance—EMT Transport Supplemental Application
- Ambulatory Surgery Center Supplement
- Clinical Research Organizations Clinical Trials Liability Insurance Application
- Durable Medical Equipment Supplemental Application
- Group Home Supplemental Application
- Home Healthcare—Medical Staffing Agency—Hospice Supplemental Application
- Ketamine Supplemental Application
- Medical Laboratory Supplement Application
- Outpatient Counselors and Counseling Supplemental Application
- Pharmacy Supplemental Application
- Physician Supplemental Application
- Schools Supplemental Application
- Substance Abuse Addiction Treatment Supplemental Application
- Telemedicine Supplemental Application
- Urgent Care and Walk-In Clinic New Business Application
Excess
Additional
- 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 Errors and 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
- Plan Purchaser Errors and Omissions Liability Update Questionnaire
- 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 (To be used only for California, Utah, and District of Columbia)
- Healthcare Organizations Management Liability Insurance Renewal Application (To be used for all other states)