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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.

#4. Largest insurer in the U.S.

OMIC is the largest insurer of ophthalmologists in the United States and we've been the only physician-owned carrier to continuously offer coverage in all states since 1987 (pending in WI). Our fully portable policy can be taken with you wherever you practice. Should you move to a new state or territory, you're covered without the cost or headache of applying for new coverage.

61864684