Your AOA Membership ID Number (if known)

Please provide your AOA Membership ID Number in order to ensure a direct match with our AOA member database.


Provide the following information. Fields with a * are required.

 

Your Malpractice (Professional Liability) Policy Effective Date
calendar*

Full Name as stated on your current policy *

Mailing Address *

City *

State *

Zip Code *

County *

Email Address *

Phone Number

Policy Limits *

Do you work Full Time or Part Time?* Full Time Part Time

Is this your first year of practice?* Yes No

Do you work in a group practice?* Yes No

If yes, how many optometrists are in your practice? *
(enter 0 if not in a group practice)



If you purchase business insurance (property & liability to cover your optometry practice please provide your Businessowners Policy
Effective Date:


calendar



Questions or Comments


   
 

 

The AOA Insurance Alliance is administered by Lockton Risk Services | 888.343.1998 | info@aoainsurancealliance.com