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Scuba Diving Questionnaire

Complete what you know and submit. Anything you leave blank will not stop the submission, but the more detail you give an underwriter, the faster we can shop the case.

Download the printable PDF

Agent & Case Information

Agent Name(Required)

Proposed Insured

Client Name(Required)
You may enter client initials. We don't share client information with carriers on risk assessments.
Sex(Required)
Tobacco / Nicotine Use(Required)

Coverage Requested

Type of Insurance

Scuba Diving Questionnaire

For each depth band (0 to 75 feet, 76 to 125 feet, 126 to 150 feet, over 150 feet), give number of dives in the past year, average time per dive, number of dives planned next year, and average time per dive.
Is the proposed insured a certified diver?
Is the proposed insured a member of an organized club?
What type of equipment does the proposed insured use?
Where does the proposed insured dive?
Does the proposed insured dive for salvage or exploration?
Has the proposed insured ever had an accident while scuba diving?
Is the proposed insured currently taking any medication(s)?

Attachments

Drop files here or
Max. file size: 512 MB.
    Attach medical records, lab slips, pathology or test reports.

    Questions before you submit? Call the underwriting desk at 866.639.0443.