SCUBA Diving Questionnaire

Company

This field is for validation purposes and should be left unchanged.

To be completed by Proposed Insured

Date of Birth*

Policy Number*

If commercial, what is the nature?

Dive Depth and Frequency

Over 100 Feet

Number of Dives*

Average Time*

Next 12 Months – Number of Dives*

Under 100 Feet

Number of Dives*

Average Time*

Next 12 Months – Number of Dives*

If yes, how often and when was the last time? (M/Y)

If yes, please explain

9. Additional remarks and information:

I understand that my answers to this questionnaire are material to my application for insurance and will be relied upon by the Company in determining my insurability.

I understand that any material misstatement in this questionnaire, or elsewhere in my application for insurance, will permit the Company to decline my application or rescind the policy.

I declare that the above answers are complete and true, and shall form part of my application to RF&G Life Insurance Company Limited.

Proposed Insured’s Signature*

Proposed Insured’s Signature

Date*

Date

Witness*

Witness

Dive Depth and Frequency

Useful Links

Contact Info