This online application is the same length and requires the same information as the application that can be mailed to you or printed from our web site.

Some of the required information you will need to gather for the application: claims made policy retroactive date, license number, board certifications, education information, previous carrier information from last three years, work history and claim information.

If you are requesting a quote and do not want to apply at this time, please return to the quote page or go back to the TMIC Dental homepage.

Instructions:

• THIS IS NOT A BINDER OR ACCEPTANCE OF INSURANCE
  
  Coverage will not be considered until this application is completed, signed and dated. Failure to provide complete information/attachments as requested will cause delay.
  
  

• PROCESSING TIME FOR MOST APPLICATIONS IS 24 TO 48 HOURS
  
  

• COVERAGE WILL NOT BE BOUND WITHOUT THE PARTIAL PAYMENT
  
  A down payment of 25% of premium must be submitted before coverage can be effected. The deposit can be made by check or credit card. To make a credit card payment, you will need to contact our office at 1-800-580-8658 and ask for the Sales Department.
  
  

• TO COMPLETE THE APPLICATION PROCESS, YOU MUST SIGN AND DATE THE ATTACHED FORMS BEING SENT TO YOUR EMAIL ADDRESS.
  
  

• TMIC ADDRESS:
  
  TMIC Address: 901 S. Mopac Expwy., Barton Oaks Plaza V, Ste. 500, Austin, TX 78746-5942
  TMIC Mail: P.O. Box 160140, Austin, TX 78716-0140
  TMIC Phone: 800-580-8658
  Sales Fax number: 512-425-5998