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First Name:

Last Name:

Address:

City:

County:

State:

Zip Code:

Phone Number:

Work Number:

Email Address:

What state(s) do you practice in?

How many locations do you have?

How many hours do you practice at each location?

Do you have current coverage?

Yes No

Do you carry the $1 million/$3 million of liability?

Yes No

When does your current policy expire?

Is your current professional liability policy claims-made or occurrence?

Claims-Made Occurrence

If it is a claims-made policy, what is the prior acts date?

If it is a claims-made policy, what are the retroactive dates?

Have you had any claims filed against you?

Yes No

Do you have separate limits of liability naming a corporation or have an additional insured listed on the policy?

Yes No

Have you ever had insurance with the AAOIC?

Yes No

Have you completed a risk management course
through the AAO this year?

Yes No

Have you received an honorable military discharge?

Yes No

If so, when?

How did you hear about us?

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