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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.

#5. Expertise unmatched.

OMIC's sole mission is to serve ophthalmology. The premier source of ophthalmic claims data and loss prevention materials, OMIC's member hotline is the most used ophthalmic consultative service of its kind and OMIC.com is the most visited web site in America for ophthalmic risk management advice and patient consent documents.

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