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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: ; Non-Ophthalmic: ; procedures.
If shared limits give above numbers ONLY for non-practice utilizers of your facility.
Coverage for Medical Spas is provided at no extra charge if limits are shared with the owner-ophthalmologist/entity.
Please indicate if required limits are:



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.

Consistent return of premium.

Publicly-traded insurance companies exist to make profits for shareholders while physician-owned carriers often return profits to their policyholders. Don’t underestimate this benefit; it can add up to tens of thousands of dollars over the course of your career. OMIC has one of the most generous dividend programs for ophthalmologists and has returned more than $90 Million to our members through dividends.

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