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Diving Underwriting Questionnaire

Agent's Name: *

First

Last

Agent's Phone Number: *

Agent's Email: *

State of Issue/Delivery: *

Send to Additional Email?

Proposed Insured's Name: *

First

Last

Sex: *

Male
Female

What is the proposed insured's: *

Date of Birth
Age

Please select "age" if the date of birth is unknown.

Date of Birth: *

Age: *

Height: *

Weight: *

Ever a marijuana/THC user? *

Current marijuana/THC user? *

How is/was the marijuana or THC consumed? *

Smoked
Drops
Pills
Vape
Other

Please describe: *

Quantity used per occasion: *

How often do/did you use marijuana or THC? *

Ever a cigarette smoker? *

Current cigarette smoker? *

Date last used:

Any other tobacco use? (cigar, pipe, snuff/chew, patch, gum, e-cigarette, etc.) *

Please provide details for any other tobacco use:

Last date any form of tobacco was used:

Is this case being premium financed? *

Do you have a lender? *

Insurance Type: *

Term
Permanent
Survivorship
Asset-Based Life/LTC hybrid product

Face Amount: *

Are there multiple policies/face amounts?

Face Amount:

Are you requesting any riders?

Type of rider:

Waiver of premium
Child term rider
LTC/CI type rider
Other

Please specify:

Diving

How many years has the proposed insured been diving?

Type of diver:

Pleasure Diver
Professional Diver

Please explain (e.g. instructor, Coast Guard, Diving for pay, etc.)

Does the proposed insured participate in:

Cave Diving
Wreck Diving
Salvage Diving
Free Diving

Please provide details:

Cave Diving

Please provide details:

Wreck Diving

Please provide details:

Salvage Diving

Please provide details:

Free Diving

Type of equipment used:

Has the proposed ever dived alone?

Date of last dive:

Certifications:

Is the proposed a member of any organized clubs?

Provide name(s):

Average dive depths:

Deepest Dive:

How often does the proposed dive this deep?

Dive location(s):

How often does the proposed dive per year?

Bodies of water:

Lakes
Rivers
Pits/Quarries
Oceans/Open Water

Number of Dives During the past 12 months

Number of Dives During the past 12 months : < 50 feet:/Average time per dive

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Last

Number of Dives During the past 12 months: 50-100 feet/Average time per dive

First

Last

Number of Dives During the past 12 months: 101-150 feet/Average time per dive

First

Last

Number of Dives During the past 12 months: >150 feet/Average time per dive

First

Last

Number of Dives contemplated in next 12 months

Number of Dives contemplated in next 12 months: < 50 feet:/Average time per dive

First

Last

Number of Dives contemplated in next 12 months: 50-100 feet/Average time per dive

First

Last

Number of Dives contemplated in next 12 months: 101-150 feet/Average time per dive

First

Last

Number of Dives contemplated in next 12 months: >150 feet/Average time per dive

First

Last

Does the proposed insured take any medications (prescription or otherwise) at this time?

Medication 1:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Medication 2:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Medication 3:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Medication 4:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Medication 5:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

More than five medications?

Name of Medication (Prescription or Otherwise), Date Started Using, Date Stopped Using, Quantity Taken, and Frequency Taken:

Please provide additional details about the proposed insured’s medical history and provide any information that would help us negotiate the lowest rates (change in lifestyle, marriage, children, etc.):

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Diversified Brokerage Services, Inc.

5501 Excelsior Blvd
Minneapolis, MN 55416
Phone 800.869.1DBS / 952.697.5000
Fax 952.697.5001

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Securities offered through The Leaders Group, Inc. Member FINRA/SIPC. 26 W. Dry Creek Circle, Suite 800, Littleton, CO 80120, 303.797.9080. Diversified Brokerage Services is not affiliated with The Leaders Group, Inc.

Before investing, research the background and registration status of any firm or financial professional you are considering dealing with at: http://brokercheck.finra.org/