8       901 Mopac Expressway South Barton Oaks Plaza V, Suite 500 Austin, Texas 78746-5942   P.O. Box 160140 Austin, Texas 78716-0140   512-425-5800 800-580-8658 Fax: 512-425-5998     TMIC Dental is a wholly owned subsidiary of Texas Medical Liability Trust           Request A Quote Please call the sales department at 800-580-8658. Apply for coverage TMIC dental application (PDF) 1. Print, complete and sign the application 2. Mail or fax the application to TMIC 3. Submit your check for 25% of the annual premium along with your application Back to homepage Texas Medical Liability Trust   Questions or Comments? Contact Webmaster     Request a Quote Steps General Information * Dentist Name (First) (Middle - optional) (Last) Practice Name (If applicable) * E-mail * Mailing Address * City * State Choose a state Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New York Newfoundland North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming * Zip Code * Office Phone () - (000) - 0000000 Home Phone () - (000) - 0000000 Office Fax () - (000) - 0000000 * Preferred Method Choose... Mail Office Phone Fax E-mail Home Phone Practice Information * Dental Specialty Choose... General Dentists Endodontics Pedodontics Periodontics Prosthodontics Orthodontics Oral Pathology Oral Surgery Other - specify below Other Specialty (if applicable) * Practice County Practice City Practice Zip Code * Current Carrier * Expiration Date (Ex: 02/25/2000) Average number of practice hours per week Professional Liability Coverage Limits indicated below are 'each claim' / 'all claims'. * Claims Made $200,000/$600,000 $500,000/$1,000,000 $1,000,000/$3,000,000 * Retroactive Date (Ex: 02/25/2000) * Are you requesting Prior Acts (nose coverage) from TMIC? Yes No or * Occurrence $200,000/$600,000 Procedures Select all procedures that apply Implants - Abutment Only Implants - Surgical Placement Third Molar extractions - partial bony Third Molar extractions - fully impacted * Is your practice limited to local or nitrous oxide? Yes No * Do you perform conscious sedation? Yes No * Do you perform general anesthesia? Yes No * Do you perform Orthodontic full-mouth banding, Malocclusions Class 1? Yes No * Do you perform Orthodontic full-mouth banding, Malocclusions Class 2 and 3? Yes No Referral and Comments How did you hear about TMIC Dental Choose... Ad in TDA Journal Direct Mail Professional convention Dentist/Colleague referral Referral - i.e. agent Previously quoted Internet Why are you considering TMIC Dental Choose... Industry Rate Reduction Comparison Shopping Non-Renewed Customer Service Issues Price - Renewal Increase Other - specify below If you choose Other, please explain why. Review hi Thank You Your request has been sent. If you entered an e-mail address, you should receive a confirmation of your submission momentarily. You should receive your quotation(s) in 5-7 business days. Established in 1995, Texas Medical Insurance Company (TMIC) is a wholly owned subsidiary of Texas Medical Liability Trust, the leading medical liability carrier for Texas physicians. TMIC is Texas-based and offers coverage that has been specifically designed for Texas dentists. Sending . . . * Required Information This online form works best in the Internet Explorer or Firefox browsers on Windows systems and Safari or Firefox browsers for Macs.