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Medical Protective - Malpractice Insurance for Optometrists

The MedPro Group, the official partner with Chiropractic Protector Plan who manages all the insurance products. Medical Protective has 100 years of experience which makes them industry's leaders in term of rating.

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Medical Protective - Malpractice Insurance for Optometrists

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  1. Medical Protective E-Sign Form To assist you with the application process, please call one of our OPP Account Executives to complete the application by phone, toll-free at 1-888-297-5230, or complete and sign this form and return via fax to (813) 222-4370 or by email to info@oppinsurance.com. Please complete and fax or email back to us at: Email: info@oppinsurance.com Fax: (813)222-4370 New Client* DATE COMPLETED _________________ Existing Insured State _________ EFFECTIVE DATE _________________ NAME OF APPLICANT _____________________________________________Lic #____________ State(s) Licensed in ________________ License Status IF YOU ARE A LEGAL ENTITY PROVIDE: FEIN_____________________________ Date of Incorporation ____________ State Entity Formed______________ Active Inactive Pending/Temporary NAME OF YOUR LEGAL ENTITY: ____________________________Type of Entity: Corporation Partnership LLC Other ____________________ IF YOU HAVE A “DBA” PROVIDE NAME:_______________________________________________________________________________________________ IS COVERAGE DESIRED FOR LEGAL ENTITY: YES NO SHARED LIMITS SEPARATE LIMITS CONTACT INFORMATION: NAME: _______________________________________________________ EMAIL: _______________________________ CELL#____________ _____________ WORK PHONE: ___________________________ HOME PHONE:____________________________FAX: _________________________________ LIST OF THOSE PROVIDING SERVICES IN OFFICE: (IF NONE ENTER Ø) TYPE Optometrist Physician/Ophthalmologist Optometric Tech Opticians Ophthalmic Tech Total Number in Practice Location(s) Total Number Requesting Shared Limits NOT AVAILABLE NOT AVAILABLE Total Number Requesting Separate Limits COMPLETE FOR ALL PRACTICE LOCATION(S): (must total 100%) Loc # 1 _______% of Practice Type: Address: _______________________________________________________________________________________________________ Practice Name Street Suite City State Zip County Association with Practice Owner of listed practice Employee Independent Contractor Office Hospital Surgical Center Other __________________________ Loc # 2 ______ % of Practice Address: _______________________________________________________________________________________________________ Type: Office Hospital Surgical Center Other __________________________ Practice Name Street Suite City State Zip County Association with Practice Mailing Address: __________________________________________________________________________________________________ Owner of listed practice Employee Independent Contractor Street Suite City State Zip COVERAGE(S) DESIRED: PROFESSIONAL LIABILITY Occurrence Claims Made: Need Retro Date_________________ LIMITS: GENERAL LIABILITY (Limits need to be the same as the Professional Liability Limits) LIMITS: EMPLOYMENT PRACTICES LIABILITY: Limit CALIFORNIA 1,000,000/$3,000,000 2,000,000/$4,000,000 VIRGINIA ONLY: $2,250,000/$6,750,000 1,000,000/$3,000,000 $500,000/Deductible $2500 2,000,000/$4,000,000 $50,000/Deductible $2500 ARKANSAS ONLY $100,000/Deductible $2500 MINNESOTA ONLY $100,000/Deductible $2500 If you are an Independent Contractor or Business Entity are you required to name an Additional Insured to your Professional Liability policy? Additional Insured Name_____________________________________________________ Mailing Address _________________________________________________ Are you covered by another Professional Liability Policy Yes NO Is coverage only needed for Moonlighting (Moonlighting coverage is available if you are covered by your employer & only need coverage working elsewhere for 10 hours or less weekly) Yes No OPTOMETRIST INFORMATION: Name Date of Birth MM/DD/YY Date MM/YY MM/YY YES NO Graduation First Date in Practice Degree Type # of Hours Work Weekly Any claims Y/N Location Number Association Membership *New Clients Current Carrier:______________________________ Occurrence Claims Made: Retro Date________ Please provide the following Information Limits: Other __________________________________ 1,000,000/$3,000,000 $2,000,000/$4,000,000 Policy term: ___/___/___ to ___/____/____ Optometric Protector Plan® - Serving Eye Care Professionals Since 1973 PO Box 173166● Tampa, FL 33672 ● Toll Free: 888-297-5230 ● Fax: (813) 222-4370 National Administrator – B & B Protector Plans, Inc., a wholly owned subsidiary of Brown & Brown

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