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Physician Name
Retroactive Date
Liability Limits
Hours Per Week
Medical Or Surgical
1
2
3
4
5
6
7
8
9
10


Coverage Needed For:
    If yes, how many?    

    If yes, how many?    

Coverage for OSFs at shared limits is provided at no extra charge if limited to practice members.
Please indicate if required limits are:


If separate limits, please list annual number:
Ophthalmic: ; Refractive: ; Non-Ophthalmic: ; procedures.
If shared limits give above numbers ONLY for non-practice utilizers of your facility.


Physicians Perform:


* Located on policy declarations page of claims-made policy (IF POLICY IS "OCCURENCE" FORM CHECK HERE)





Six reasons OMIC is the best choice for ophthalmologists in America.

#2. Leader in the industry.

A-rated by AM Best, OMIC is ranked #1 among 50 malpractice insurance companies in America for financial stability. No other carrier has matched OMIC's consistent financial performance with regard to both combined and operating ratios, the two most relevant financial measurements for an insurance carrier.

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