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Diving Underwriting Questionnaire
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Agent's Name:
*
First
Last
Agent's Phone Number:
*
Agent's Email:
*
State of Issue/Delivery:
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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:
*
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Age:
*
Height:
*
Weight:
*
Ever a marijuana/THC user?
*
Yes
No
Current marijuana/THC user?
*
Yes
No
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?
*
Yes
No
Current cigarette smoker?
*
Yes
No
Date last used:
MM
1
2
3
4
5
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8
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11
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DD
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1922
1921
1920
Any other tobacco use? (cigar, pipe, snuff/chew, patch, gum, e-cigarette, etc.)
*
Yes
No
Please provide details for any other tobacco use:
Last date any form of tobacco was used:
MM
1
2
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4
5
6
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8
9
10
11
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DD
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YYYY
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2008
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1932
1931
1930
1929
1928
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1926
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1921
1920
Is this case being premium financed?
*
Yes
No
Do you have a lender?
*
Yes
No
Insurance Type:
*
Term
Permanent
Survivorship
Asset-Based Life/LTC hybrid product
Face Amount:
*
Are there multiple policies/face amounts?
Yes
No
Face Amount:
Are you requesting any riders?
Yes
No
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?
Yes
No
Date of last dive:
MM
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DD
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YYYY
2023
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2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
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1933
1932
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1930
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1928
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1926
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1922
1921
1920
Certifications:
Is the proposed a member of any organized clubs?
Yes
No
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
First
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?
Yes
No
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?
Yes
No
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.):
Submit
