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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.

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. 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.

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