Application Forms
- To Add an Insured
- Entity (including partnerships, multi-shareholder corporations, and sole shareholder corporations)
- Eye Bank
- Locum Tenens
- Medical Spa
- Nurse Anesthetist (CRNA)
- Optical Shop
- Optometrist
- Outpatient Surgical Facility
- Physician
If the physician practices in Kansas or Nebraska, please click on the applicable state to download a state-specific supplemental questionnaire. - Slot Occupant
- Contact Us
If the health care provider has one or more office locations in Kentucky, please click here for a state-specific questionnaire.
- To Add a Procedure
- Audiology Services
- Conductive Keratoplasty
- Cosmetic Full Facelift
- Intacs
- LASIK
- Liposuction
- Phakic Implants
- PRK
- Radial and Astigmatic Keratotomy (RK/AK)
- Refractive Lens Exchange (RLE)
- Retinopathy of Prematurity (ROP)
- Remote Screening for Retinopathy of Prematurity
- Rhinoplasty
- Review of Advertisement for Medical Services Addendum
- To Change a Coverage
To access the forms below, you will be prompted to enter the insured name and client ID as found on your Declarations.






