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Malpractice Insurance Application
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Applicant Information
Policy Information
Business Entity & General Liability
Review
Acknowledgements
Your completed application becomes part of the policy should you choose to purchase coverage through the AOA Liability and Business Insurance Program.
Please note: Your O.D. designation will automatically be displayed on all policy documents. Please do not include the designation when entering your name below.
Optometrist
#1
First Name
Middle Initial
Last Name
Birth Date
(mm/dd/yyyy)
AOA Member Number
Primary Business Address
Apt/Suite
City
State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
County
Zip Code
Phone Number
Fax Number
Email Address
License Number
Additional License Number
Additional License State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Average Number of Hours you Practice per Week
Are you in your first year of practice?
Yes
No
Date you
first
began practicing optometry
(mm/dd/yyyy)
Education
Optometry School Name
City
State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Graduation Date
(mm/dd/yyyy)
Postgraduate School Name
City
State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
GU
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Graduation Date
(mm/dd/yyyy)
Underwriting
Are you under contract, or planning to enter into a contract, with any third-party employer or any Prison Facility (federal, state or county detention or correctional center, whether operated directly by the government entity or contracted to a privately owned operator) to offer Professional Services to any incarcerated individuals who are serving a sentence of one year or longer?
Yes
No
If YES, Please call 888-343-1998 to speak with one of our licensed agents. This policy may not cover you for professional services provided under contract through a third-party employer or with a Prison facility directly.
Do you have existing malpractice insurance?
Yes
No
During the last five years, has this applicant had his/her optometry license subject to probation, suspended, revoked, voluntarily surrendered by you or
has a complaint been filed against you or any of your employees or is such an action pending?
Yes
No
During the last five years, have you or any of your employees ever had malpractice insurance declined, denied renewal, placed on probation, cancelled
or issued on a restricted basis?
Yes
No
During the last five years, has applicant ever been convicted of or pled no contest to a violation of any law or ordinance other than minor traffic offenses?
Yes
No
During the past five years, has any claim or suit been brought against you or any of your employees resulting in damages or defense costs in excess of $500? Are you or any of your employees aware of any incident that might reasonably lead to a claim or suit?
Yes
No
Application # 49408541