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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.

Supporting your specialty.

OMIC was founded by members of the American Academy of Ophthalmology nearly a quarter century ago and is the only carrier sponsored and endorsed by AAO. OMIC is also endorsed by 54 other ophthalmic societies. The OMIC partnerships with state and subspecialty societies qualifies their members for an exclusive 10% premium credit. Contact your state society for details.

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