Eye Care Professional Program Form

Name of Applicant:
Street Address City State / Province / Region ZIP / Postal Code
Licensed States
License #
FEIN
Date of Incorporation
MM slash DD slash YYYY
Entity Type
- Corporation
- LLC
- Partnership
Number of Employees:
Optometrist
Total Number Total Requesting Shared Limits Total Requesting Separate Limits
Physician/Ophthalmologist
Total Number Total Requesting Shared Limits Total Requesting Separate Limits
Optometric Tech
Total Number Total Requesting Shared Limits Total Requesting Separate Limits
Opticians
Total Number Total Requesting Shared Limits Total Requesting Separate Limits
Ophthalmic Tech
Total Number Total Requesting Shared Limits Total Requesting Separate Limits
Other
Total Number Total Requesting Shared Limits Total Requesting Separate Limits
Annual Gross Sales
Full Time Employees
Part Time Employees
Total Annual Payroll
General Liability Limits Desired
Professional Liability Limits Desired
Are you required to name any Additional Insured’s to your Professional Liability Policy?
- Yes
- No
Are you covered by any other Professional Policy?
- Yes
- No
Is coverage only needed for moonlighting?
- Yes
- No
Practice Location Information: (please provide additional pages if more than one location – total must equal 100%)
%of operations at this location
Type
- Office
- Hospital
- Surgical Center
- Other
Current Carrier
- Occurrence
- Claims Made
Current Policy Term
Optometrist Info:
Name DOB Graduation Date First Date In Practice Degree # Hours Worked Weekly Any Claims

We work harder for you.Call us old fashioned, but we actually read through your policies
and give you what you want, need, and deserve.

Total Number	Total Requesting Shared Limits	Total Requesting Separate Limits

Total Number	Total Requesting Shared Limits	Total Requesting Separate Limits

Total Number	Total Requesting Shared Limits	Total Requesting Separate Limits

Total Number	Total Requesting Shared Limits	Total Requesting Separate Limits