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Optometrist Professional Liability

Insurance Application

INSTRUCTIONS
A. Please read the instructions carefully. Complete and submit all requested information and/or required attachments.
This application and all materials submitted shall be held in confidence.
B. All application questions must be fully answered. If a question does not apply, please write N/A.
C. If more space is needed, continue on a separate sheet of the applicants letterhead and indicate the question
number.
D. This application must be completed, signed and dated by a principal of the business.
GENERAL INFORMATION
1. Are you an individual or group practice? Individual Group
If a group practice, how many optometrists are in your group? ________
2. Are you, or is anyone in your practice, practicing in multiple states? Yes No
3. What Liability Limits of Insurance do you need? $________________
4. If an individual, do you require corporation/partnership coverage? Yes No
5. If an individual, do you require Workplace Liability coverage? Yes No
6. What is your desired effective date? ________________
Please complete the schedule below for each optometrist:
First Name Middle Last Name Years of Hours worked Licensed Optometrist or Student
Initial Practice per week

If there are more than 10 optometrists in your group, please complete the supplemental application at the end of
the application for the additional optometrists.
7. Name of Contact: _______________________________________________________________________________________
8. Name of Entity (if applicable):_____________________________________________________________________________
9. Type of Entity (if applicable): Partnership Joint Venture Trust Limited Liability Company
Organization, including a corporation (but not including a partnership, joint venture or limited liability company)
10. Business Address: _________________________________________________________________________________________
City: ______________________________ State: ___________ Zip Code: ____________ County: __________________
Mailing Address (if different): _______________________________________________________________________________
Telephone Number: ____________________ Fax Number: ________________ Website:__________________________
Email Address:____________________________________________________________________________________________

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The Hanover Insurance Company | 440 Lincoln Street, Worcester, MA 01653


126-10013 (3/17) Page 1 of 11 Campmed Casualty & Indemnity Company, Inc. | 12100 Sunset Hills Road, Suite 300, Reston VA 20196-3295 hanover.com
Please complete the schedule below for each optometrist:
First Name Last Name Date of Birth Medicare Current Professional Liability Insurer
Provider ID

If there are more than 10 optometrists in your group, please complete the supplemental application at the end of
the application for the additional optometrists.

For each optometrist who provides surgical services, please provide the following details:
First Name Last Name Number of Surgeries Type of Surgeries
Per Year

If more than 10 optometrists in your group perform surgery, please complete the supplemental application at the
end of the application for the additional optometrists.

Education
Please complete the schedule below for each optometrist:
First Name Last Name Optometry School School City/State Year Post-Graduate Post-Graduate
or College Graduated Training Program Training
Graduation
Date

more

The Hanover Insurance Company | 440 Lincoln Street, Worcester, MA 01653


126-10013 (3/17) Page 2 of 11 Campmed Casualty & Indemnity Company, Inc. | 12100 Sunset Hills Road, Suite 300, Reston VA 20196-3295 hanover.com
First Name Last Name Optometry School School City/State Year Post-Graduate Post-Graduate
or College Graduated Training Program Training
Graduation
Date

If there are more than 10 optometrists in your group, please complete the supplemental application at the end of the
application for the additional optometrists.

Licensing
Please complete the schedule below for each optometrist. If you are licensed in more than one state, please
use additional lines to indicate additional state licenses.
First Name Last Name License Number License State Average Hours Board DEA License
Per Week Certification(s) Number
Worked in State

If there are more than 10 optometrists in your group, please complete the supplemental application at the end of the
application for the additional optometrists.

1. Are there any special designations or levels to the license for any of the optometrists? Yes No
If so, please provide the name of the optometrist and describe the designations:
___________________________________________________________________________________________________
Additional Insureds
Additional insured coverage may be added to the Professional Liability and Workplace Liability Coverage parts on a
shared limit of liability basis when required by contract.
Individuals and entities may be added as Additional Insureds automatically when required by contract, or may be
individually scheduled on the policy. Such additional insureds shall be covered for their vicarious liability only as their
interest appears, as specified by the additional insured endorsement by which they are added to the policy.
Please select the additional insured when required by contract coverage you would like to add to the policy:

Additional Insured When Required by Contract for Professional Liability:


Contract for professional services provided by the Named Insured to the additional insured

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The Hanover Insurance Company | 440 Lincoln Street, Worcester, MA 01653


126-10013 (3/17) Page 3 of 11 Campmed Casualty & Indemnity Company, Inc. | 12100 Sunset Hills Road, Suite 300, Reston VA 20196-3295 hanover.com
Additional Insured When Required by Contract for Workplace Liability:
Contract for work performed by the Named Insured for the additional insured
Contract with the additional insured for premises that the Named Insured owns, rents, leases, controls or occupies
Contract for equipment leased to the Named Insured by the additional insured
Please provide the information requested below for each scheduled additional insured you would like to add to the
policy:

Additional Insured by Schedule for Professional Liability:


Coverage only applies with respect to professional services provided by the Named Insured.
1. Additional Insured Name: _____________________________________________________________________________
2. What are the operations of the additional insured? _______________________________________________________
3. What is the relationship between the Named Insured and the additional insured? ____________________________
4. What professional services is the Named Insured performing for the additional insured?
____________________________________________________________________________________________________
5. Is there a contractual obligation to add the above person or entity as an
additional insured on the policy? Yes No
6. Does the additional insured maintain their own insurance to cover their
operational exposures? Yes No
If you need to add more than one Additional Insured by Schedule to the Professional
Liability policy, please complete the attached supplemental application.

Additional Insured by Schedule for Workplace Liability:


1. Additional Insured Name: _____________________________________________________________________________
2. What are the operations of the additional insured? _______________________________________________________
3. What is the relationship between the Named Insured and the additional insured?
Named Insured is performing work for the additional insured. Type of work: ______________________________
Named Insured rents, leases, controls or occupies premises owned by the additional insured
Named Insured leases equipment from the additional insured
Other: ___________________________________________________________________________________________
4. Is there a contractual obligation to add the above person or entity as an additional
insured on the policy? Yes No
5. Does the additional insured maintain their own insurance to cover their
operational exposures? Yes No
If you need to add more than one Additional Insured by Schedule to the Workplace
Liability policy, please complete the attached supplemental application.

Underwriting:
1. Does the applicant have existing professional liability insurance? Yes No
a. Current Insurance Carrier: _____________________________________________ Premium: $_______________
b. Current Form of Insurance (Check one): Claims Made Retroactive Date: ____________ Occurrence
c. Current Limits of Liability: $________________ each claim $________________ aggregate
2. Does the applicant require Corporation/Partnership coverage? Yes No
If Yes, do you wish a Shared Limit or Separate Limit?

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The Hanover Insurance Company | 440 Lincoln Street, Worcester, MA 01653


126-10013 (3/17) Page 4 of 11 Campmed Casualty & Indemnity Company, Inc. | 12100 Sunset Hills Road, Suite 300, Reston VA 20196-3295 hanover.com
3. Does the applicant have existing:
a. Workplace Liability coverage? Yes No
b. Commercial General Liability coverage? Yes No
i. Current Insurance Carrier: _________________________________________ Premium: $_______________
ii. Current Form of Insurance (Check one): Claims Made Retroactive Date: ____________
Occurrence
iii. Current Limits of Liability: $________________ each claim $________________ aggregate
4. Does the applicant require Commercial General Liability coverage? Yes No

If the response is Yes to any question below, additional information must be provided on the applicants
letterhead. Please submit actual loss runs from the previous carriers for the past five or more years.
A. During the last 5 years, have any claims or suits been brought against any
of the applicants? Yes No
If Yes, describe: _____________________________________________________________________________________
B. Are the applicant(s) or any of the applicants employees aware of any incident
(including requests for medical records), circumstance or occurrence which may
result in a claim and which has not been reported to another carrier? Yes No
If Yes, describe: _____________________________________________________________________________________
C. During the last 5 years, have any of the applicants had his/her optometry license
subject to probation, suspension, revocation, or voluntary surrender, or is such an
action pending? Yes No
If Yes, describe: _____________________________________________________________________________________
D. Has the facility or operational license of any applicant that is an entity, group,
company or organization ever been suspended, revoked or voluntarily suspended? Yes No
If Yes, describe: _____________________________________________________________________________________
E. Has any insurance company or Lloyds declined, canceled, or refused to renew
or accept any of the applicants liability insurance? Yes No
Missouri Applicants: Do Not Respond to this Question
If Yes, describe: _____________________________________________________________________________________
F. Has any entity, group, company or organization with whom any of the applicants
have been previously affiliated become insolvent? Yes No
If Yes, describe: _____________________________________________________________________________________
G. Has any federal or state civil or criminal investigation or action been initiated or filed
that directly or indirectly involves the applicants entity, group, company or organization? Yes No
If Yes, describe: _____________________________________________________________________________________
H. Have any of the applicants ever been sanctioned or decertified by Medicare? Yes No
If Yes, describe: _____________________________________________________________________________________
I. Has the entity, group, company or organization or any of its officers, administrators,
or staff been sanctioned or had disciplinary actions brought against them by
federal or state authorities, any professional medical society, accreditation agency
or other governmental or non-governmental oversight entity? Yes No
If Yes, describe: _____________________________________________________________________________________

more

The Hanover Insurance Company | 440 Lincoln Street, Worcester, MA 01653


126-10013 (3/17) Page 5 of 11 Campmed Casualty & Indemnity Company, Inc. | 12100 Sunset Hills Road, Suite 300, Reston VA 20196-3295 hanover.com
J. During the last 5 years, have any of the applicants or anyone in the entity, group,
company or organization been convicted of or plead no contest to a violation of
any law or ordinance other than minor traffic offenses? Yes No
If Yes, describe: _____________________________________________________________________________________

AUTHORIZATION
By signing this application, I declare that I have reviewed this application for accuracy before signing it,
that I have answered the questions in this application to the best of my ability and that, to the best of
my knowledge following reasonable inquiry, the statements set forth herein are true, complete, accurate
and correct and no material facts have been omitted, misrepresented, or misstated. My signing of this
application does not bind the insurance company to complete the insurance, but it is agreed that this
application shall be the basis of the contract should a policy be issued.

FRAUD NOTICE Where Applicable Under The Law of Your State


Any person who knowingly and with the intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false or incomplete information,
or conceals for the purpose of misleading, information concerning any fact material thereto, commits a
fraudulent insurance act, which is a crime and may be subject to civil fines and criminal penalties.

Notice to Alabama Applicants: Any person who knowingly presents a false or fraudulent claim for payment
of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a
crime and may be subject to restitution, fines, or confinement in prison, or any combination thereof.
Notice to Arkansas Applicants Any person who knowingly presents a false or fraudulent claim for
payment of a loss or benefit, or knowingly presents false information in an application for insurance is
guilty of a crime and may be subject to fines and confinement in prison.
Notice to California Applicants: For your protection California law requires the following to appear on
this form. Any person who knowingly presents a false or fraudulent claim for the payment of a loss is
guilty of a crime and may be subject to fines and confinement in state prison.
Notice to Colorado Applicants: It is unlawful to knowingly provide false, incomplete, or misleading
facts or information to an insurance company for the purpose of defrauding or attempting to defraud the
company. Penalties may include imprisonment, fines, denial of insurance, and civil damages. Any insurance
company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts
or information to a policyholder or claimant for the purposes of defrauding or attempting to defraud the
policyholder with regard to a settlement or award payable from insurance proceeds shall be reported to
the Colorado Division of Insurance within the Department of Regulatory Agencies.
Notice to District of Columbia Applicants: WARNING: It is a crime to provide false or misleading
information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include
imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information
materially related to a claim was provided by the applicant.
Notice to Florida Applicants: Any person who knowingly and with intent to injure, defraud, or deceive
any insurer files a statement of claim or any application containing any false, incomplete or misleading
information is guilty of a felony of the third degree.
Notice to Hawaii Applicants: For your protection, Hawaii law requires you to be informed that
presenting a fraudulent claim for payment of a loss or benefit is a crime punishable by fines or
imprisonment, or both.
Notice to Kentucky Applicants: Any person who knowingly and with intent to defraud any insurance
company or other person files an application for insurance containing any materially false information
or conceals, for the purpose of misleading, information concerning any fact material thereto commits a
fraudulent insurance act, which is a crime.
Notice to Louisiana, Rhode Island and West Virginia Applicants: Any person who knowingly presents
a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an
application for insurance is guilty of a crime and may be subject to fines and confinement in prison.

more

The Hanover Insurance Company | 440 Lincoln Street, Worcester, MA 01653


126-10013 (3/17) Page 6 of 11 Campmed Casualty & Indemnity Company, Inc. | 12100 Sunset Hills Road, Suite 300, Reston VA 20196-3295 hanover.com
Notice to Maine Applicants: It is a crime to knowingly provide false, incomplete, or misleading
information to an insurance company for the purpose of defrauding the company. Penalties may include
imprisonment, fines or a denial of insurance benefits.
Notice to Maryland Applicants: Any person who knowingly or willfully presents a false or fraudulent
claim for payment of a loss or benefit or who knowingly or willfully presents false information in an
application for insurance is guilty of a crime and may be subject to fines or confinement in prison.
Notice to New Jersey Applicants: Any person who includes any false or misleading information on an
application for an insurance policy is subject to criminal and civil penalties.
Notice to New Mexico Applicants: Any person who knowingly presents a false or fraudulent claim for
payment of a loss or benefit or knowingly presents false information in an application for insurance is
guilty of a crime and may be subject to civil fines and criminal penalties.
Notice to New York Applicants: Any person who knowingly and with intent to defraud any insurance
company or other person files an application for insurance or statement of claim containing any
materially false information or conceals, for the purpose of misleading, information concerning any fact
material thereto commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil
penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
Notice to Ohio Applicants: Any person who, with intent to defraud or knowing that he is facilitating a
fraud against an insurer, submits an application or files a claim containing a false or deceptive statement
is guilty of insurance fraud.
Notice to Oklahoma Applicants: WARNING: Any person who knowingly, and with intent to injure,
defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any
false, incomplete or misleading information is guilty of a felony (365:15-1-10, 36 3613.1).
Notice to Oregon Applicants: Any person who knowingly and with intent to defraud or solicit another
to defraud an insurer: (1) by submitting an application, or (2) by filing a claim containing a false
statement as to any material fact, may be violating state law.
Notice to Pennsylvania Applicants: Any person who knowingly and with intent to defraud any
insurance company or other person files an application for insurance or statement of claim containing
any materially false information or conceals for the purpose of misleading, information concerning any
fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to
criminal and civil penalties.
Notice to Tennessee and Virginia Applicants: It is a crime to knowingly provide false, incomplete or
misleading information to an insurance company for the purpose of defrauding the company. Penalties
include imprisonment, fines and denial of insurance benefits.
Notice to Washington Applicants: It is a crime to knowingly provide false, incomplete or misleading
information to an insurance company for the purpose of defrauding the company. Penalties may include
imprisonment, fines or a denial of insurance benefits.

Signature in full: __________________________________________________ Date: _____________________


ALL QUESTIONS MUST BE ANSWERED AND THE APPLICATION MUST BE SIGNED AND DATED

Agency Name and Address: ___________________________________________________________________


Person Submitting Application: _________________________________________________________________
Telephone Number: _____________________________________ Email: ____________________________

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The Hanover Insurance Company | 440 Lincoln Street, Worcester, MA 01653


126-10013 (3/17) Page 7 of 11 Campmed Casualty & Indemnity Company, Inc. | 12100 Sunset Hills Road, Suite 300, Reston VA 20196-3295 hanover.com
Supplemental Application for Additional Optometrists
Supplemental Application

Please complete the schedule below for each optometrist:


First Name Middle Last Name Years of Hours worked Licensed Optometrist or Student
Initial Practice per week

Please complete the schedule below for each optometrist:


First Name Last Name Date of Birth Medicare Current Professional Liability Insurer
Provider ID

For each optometrist who provides surgical services, please provide the following details:
First Name Last Name Number of Surgeries Type of Surgeries
Per Year

more

The Hanover Insurance Company | 440 Lincoln Street, Worcester, MA 01653


126-10013 (3/17) Page 8 of 11 Campmed Casualty & Indemnity Company, Inc. | 12100 Sunset Hills Road, Suite 300, Reston VA 20196-3295 hanover.com
Please complete the schedule below for each optometrist:
First Name Last Name Optometry School School City/State Year Post-Graduate Post-Graduate
or College Graduated Training Program Training
Graduation
Date

Please complete the schedule below for each optometrist. If you are licensed in more than one state, please
use additional lines to indicate additional state licenses.
First Name Last Name License Number License State Average Hours Board DEA License
Per Week Certification(s) Number
Worked in State

1. Are there any special designations or levels to the license for any of the optometrists? Yes No
If so, please provide the name of the optometrist and describe the designations:
___________________________________________________________________________________________________

more

The Hanover Insurance Company | 440 Lincoln Street, Worcester, MA 01653


126-10013 (3/17) Page 9 of 11 Campmed Casualty & Indemnity Company, Inc. | 12100 Sunset Hills Road, Suite 300, Reston VA 20196-3295 hanover.com
Additional Insured by Schedule for Professional
Liability Supplemental Application
Supplemental Application

Do all of the additional insureds requested have a combinable interest? Yes No


1. Additional Insured Name: ____________________________________________________________________________
What are the operations of the additional insured? __________________________________________________________
What is the relationship between the Named Insured and the additional insured? _______________________________
What professional services is the Named Insured performing for the additional insured? _________________________
Is there a contractual obligation to add the above person or entity as an additional
insured on the policy? Yes No
Does the additional insured maintain their own insurance to cover their
operational exposures? Yes No

2. Additional Insured Name: ____________________________________________________________________________


What are the operations of the additional insured? __________________________________________________________
What is the relationship between the Named Insured and the additional insured? _______________________________
What professional services is the Named Insured performing for the additional insured? _________________________
Is there a contractual obligation to add the above person or entity as an additional
insured on the policy? Yes No
Does the additional insured maintain their own insurance to cover their
operational exposures? Yes No

3. Additional Insured Name: ____________________________________________________________________________


What are the operations of the additional insured? __________________________________________________________
What is the relationship between the Named Insured and the additional insured? _______________________________
What professional services is the Named Insured performing for the additional insured? _________________________
Is there a contractual obligation to add the above person or entity as an additional
insured on the policy? Yes No
Does the additional insured maintain their own insurance to cover their
operational exposures? Yes No

4. Additional Insured Name: ____________________________________________________________________________


What are the operations of the additional insured? __________________________________________________________
What is the relationship between the Named Insured and the additional insured? _______________________________
What professional services is the Named Insured performing for the additional insured? _________________________
Is there a contractual obligation to add the above person or entity as an additional
insured on the policy? Yes No
Does the additional insured maintain their own insurance to cover their
operational exposures? Yes No

more

The Hanover Insurance Company | 440 Lincoln Street, Worcester, MA 01653


126-10013 (3/17) Page 10 of 11 Campmed Casualty & Indemnity Company, Inc. | 12100 Sunset Hills Road, Suite 300, Reston VA 20196-3295 hanover.com
Additional Insured by Schedule for Workplace
Liability Supplemental Application
Supplemental Application

Do all of the additional insureds requested have a combinable interest? Yes No


1. Additional Insured Name: ____________________________________________________________________________
What are the operations of the additional insured? __________________________________________________________
What is the relationship between the Named Insured and the additional insured?
Named Insured is performing work for the additional insured. Type of work:__________________________________
Named Insured rents, leases, controls or occupies premises owned by the additional insured
Named Insured leases equipment from the additional insured
Other: _______________________________________________________________________________________________
Is there a contractual obligation to add the above person or entity as an additional
insured on the policy? Yes No
Does the additional insured maintain their own insurance to cover their
operational exposures? Yes No

2. Additional Insured Name: ____________________________________________________________________________


What are the operations of the additional insured? __________________________________________________________
What is the relationship between the Named Insured and the additional insured?
Named Insured is performing work for the additional insured. Type of work:__________________________________
Named Insured rents, leases, controls or occupies premises owned by the additional insured
Named Insured leases equipment from the additional insured
Other: _______________________________________________________________________________________________
Is there a contractual obligation to add the above person or entity as an additional
insured on the policy? Yes No
Does the additional insured maintain their own insurance to cover their
operational exposures? Yes No

3. Additional Insured Name: ____________________________________________________________________________


What are the operations of the additional insured? __________________________________________________________
What is the relationship between the Named Insured and the additional insured?
Named Insured is performing work for the additional insured. Type of work:__________________________________
Named Insured rents, leases, controls or occupies premises owned by the additional insured
Named Insured leases equipment from the additional insured
Other: _______________________________________________________________________________________________
Is there a contractual obligation to add the above person or entity as an additional
insured on the policy? Yes No
Does the additional insured maintain their own insurance to cover their
operational exposures? Yes No

The Hanover Insurance Company | 440 Lincoln Street, Worcester, MA 01653


126-10013 (3/17) Page 11 of 11 Campmed Casualty & Indemnity Company, Inc. | 12100 Sunset Hills Road, Suite 300, Reston VA 20196-3295 hanover.com