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Practice name:
Street Address:
City / State / Zip:
County (or counties):
Physician Name Retroactive Date* Liability Limits Hours per Week Medical or Surgical

-- Add Another Physician --

Physician(s) Perform: Lasik/PRK    CK    Refractive Lens Exchange    Phankic Implants    INTACS
  Facelifts (cosmetic)    Liposuction    ROP Screening or Treatment
Need Coverage For: Optometrist(s)? (If yes, how many? Separate or Shared Limits?)
  Nurse Anesthetist(s)? (If yes, how many? Separate or Shared Limits?)
  OSF (Outpatient Surgical Facility - Surgery Center or Office Surgical Suite)
  Coverage for OSFs at shared limits is provided at no extra charge if limited to practice members.
  Please indicate if: shared or separate limits are required. 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.
Current policy effective date?
Who should the rate indication be sent to?
Which do you prefer? Email: Phone: Fax:


*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.