10Mar 2010 | 866 497 0836

home | Apply Online

Telephone: (866) 497.0836

Fax Machine: (319) 235.6656

E-mail: service@oandpinsurance.com
John Spragle President 866.497.0836
Amy Brocka Customer Service Agent 800.990.7351
Brenda Roth Customer Service Assistant 866.497.0836
Connie Phillis Customer Service Rep 866.497.0836
Crystal Anderson Customer Service Assistant 866.497.0836
Darla Porter Customer Service Agent 800.522.6535
David Oleson Sales Rep 800.990.6367
Janean Craig VP of Administration 800.990.7349
John Boardsen Sales Rep 800.990.7341
Melanie Kauten Accounts Payable 888.218.4581
Marilynne Fisk, AU Customer Service Agent 866.859.0172
Roxann Kouns Customer Service Agent 800.272.5271
Pam Brandt Assistant 800.205.0092
Russ Britson Underwriter 800.443.5613
Michelle Harks Legal Assistant 800.362.3363
Sharon Dufel Collections 866.904.6504
Warren G. Freeman, CFP Director of Sales and Marketing 866.904.6504

Application Instructions

Answer all questions. If the answer is "none" please state "none" or "n/a". Owner, partner or officer must sign application. This application will be attached and become part of any insurance policy issued.

If you would prefer to print the Application for Orthotic and Prosthetic Facilities and fax the application to us, please print the downloadable application.

DOWNLOAD PDF APPLICATION
OPGA/POINT MEMBER NUMBER
Effective Date

Named Insured

(full name of all companies as they are to appear in the policy)
Company Name:
DBA:
Street: P.O. Box
City: State:
Contact: Email:
Phone #: Fax:
FEIN: Medicare Provider #:
Entity: Corporation Individual Partnership Limited Partnership LLC Other
1. How many years in the field?
2. How many years operation under the same company name?
3. Are you a subsidiary of another entity or do you have any subsidiaries?

4. Limit of Liability requested: Please check one

  • $500,000
  • $1,000,000 - $3,000,000
  • $3,000,000 - $4,000,000
  • $1,000,000 - $1,000,000
  • $2,000,000 - $3,000,000
  • $4,000,000 - $4,000,000
  • $1,000,000 - $2,000,000
  • $2,000,000 - $4,000,000
  • $5,000,000 - $5,000,000
Estimated Annual Gross Receipts for the Upcoming Year:
Previous Year:

Gross Revenue Sources

(Gross revenue must be broken into percentages and must equal 100%)
Patient Care Sales:
Includes all sales of items you make, fit or alter for individual patients 		%
Supplier/Distributor:
Includes all items purchased from others that you resell to another facility or distributor		 %
Supplier/Manufacturer:
No patient contact. Includes items manufactured by you and sold to facilities (central fabrication)		 %
DME - Durable Medical Equipment & Soft Goods:
Includes items sold or rented directly to patients with no altering or re-labeling of parts, Includes pharmacy Rx, OTC and disposables.		 %
5. Do you use any independent contractors for your business (1099) ? Yes No
6. Do you employ contract or subcontract labor for service or repair of products? Yes No
7. Do you render professional services directly to patients without physician referral? Yes No
8. Do you perform or assist in any surgical procedures? Yes No

9. Have there been any claims filed or losses paid, or are you aware of any incidents which might give rise to a suit against you, within the last three (3) years?

(please attach prior carrier loss history)

 Yes No
If you answered yes to any of the questions above, please explain:
10. Please check if you would like a quote for
  • Hired and/or Non-Owned Auto $250,000 limit
          * Supplemental Application Required
  • Employee Benefits Liability $1,000,000 limit
          * Number of employees

Professional Liability

11. Please indicate the number of professionals in each category:

ABC or BOC Certified Prosthetists / Orthotists

Poedorthists

Physical Therapists

Prior Liability Insurance Experience
Carrier Name:
Carrier Names:
12. Ever carried insurance that was written on a "claims made" basis?
If claims made - Retro Date: 		Yes No

Location Information
Main Location
 Bldg. Address:

  Square Feet:    Own Lease
Location #2
 Bldg. Address:

  Square Feet:    Own Lease
Location #3
 Bldg. Address:

  Square Feet:    Own Lease

Warning!!!

THE FOLLOWING WARRANTIES WILL BE A PART OF ANY POLICY ISSUED UNDER THIS PROGRAM

This is an important document, which could effect your legal rights. Please read it again carefully and be certain it is correct and complete. Your signature below is your warranty to us that we can rely on information in this form. We have made no investigation of our own and the coverage decision will be based on this information.

COVERAGE IS NOT BOUND OR STARTED WITH THIS FORM. WE MAKE NO PROMISE TO INSURE. THIS IS ONLY A REQUEST FOR A QUOTE. YOU ARE NOT COVERED UNTIL AND UNLESS YOU RECIEVE A BINDER SO STATING.

The coverage we are quoting from information on this form is Product/Completed Operations and Professional and/or General Liability Insurance. If you have any questions about the form or your answers, please ask your sales representative.

The questions in this application are not intended to, nor do they indicate the existence, non-existence or limitations of coverage.

INCOMPLETE APPLICATIONS WILL BE REJECTED

I agree to the terms of this agreement

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