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)UnderwritingAre 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?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?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 # 12537444