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SCUBA Diving Questionnaire
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Forms
SCUBA Diving Questionnaire
SCUBA Diving Questionnaire
"
*
" indicates required fields
X/Twitter
This field is for validation purposes and should be left unchanged.
To be completed by Proposed Insured
Name
*
First
Middle
Last
Date of Birth
*
Policy Number
*
1. Purpose of diving
*
Recreational
Instruction
Hunting
Wreck/Salvage
Commercial
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
*
3. Do you engage in specialty/technical diving?
*
Yes
No
4. Level of certification
*
Basic
Open Water
Advance Open Water
Master Diver
Dive Master
5. Indicate the body of water you usually dive in
*
River
Lake
Shallow Sea
Deep Ocean
6. Do you dive alone?
*
Yes
No
If yes, how often and when was the last time? (M/Y)
7. Have you ever experienced or been treated for Decompression Illness, including Decompression Sickness (DCS) or Arterial Gas Embolism (AGE – also known as air embolism)?
*
Yes
No
If yes, please explain
8. Have you ever had a diving accident?
*
Yes
No
If yes, please explain
9. Additional remarks and information:
Acknowledgment
*
Select exactly
3
choices.
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
Witness
Date
*
Date
Δ