Malpractice Insurance Application
Skip Navigation LinksYour 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 #1First NameMiddle InitialLast NameBirth Date (mm/dd/yyyy)AOA Member NumberPrimary Business AddressCityStateCountyZip CodePhone NumberFax NumberEmail AddressLicense NumberAdditional License NumberAdditional License StateAverage Number of Hours you Practice per WeekAre you in your first year of practice?Date you first began practicing optometry (mm/dd/yyyy)EducationOptometry School NameCityStateGraduation Date (mm/dd/yyyy)Postgraduate School NameCityStateGraduation Date (mm/dd/yyyy)UnderwritingDo you, or do you plan to provide services to any patients imprisoned in a local, state or federal correctional facility at any time in the next 12 months?Please be aware that providing services to incarcerated patients at a facility or in your office may result in changes to your malpractice insurance coverage and / or rates. Please call 888-343-1998 if you have any questions or are considering changes in your practice plans regarding incarcerated patients.Do you have existing malpractice insurance?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?
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?
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?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?Application # 11261589