Scuba

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Scuba Questionnaire
Please answer all questions applicable to the client's medical history.
Questions? Call Jim or Teresa at 877.564.1707.
Producer Name*
Phone*
Email*
Date
MM slash DD slash YYYY
Client Name
Date of Birth
MM slash DD slash YYYY
Gender
- Male
- Female
Face Amount
Max Premium $/year
Type
Has the client ever used any form of tobacco (cigarettes, cigars, pipe, snuff, etc)?
- Yes
- No
Frequency
Date of Last Use
Type
How many years has the client been diving?
Type of diving:
- Pleasure diver
- Professional diver
If professional, please explain (e.g. instructor, Coast Guard, etc.):
Does the client participate in:
- Cave diving
- Wreck diving
- Salvage diving
If any are selected, provide details:
Type of equipment used:
Does the client ever dive alone?
- Yes
- No
Date of last dive:
MM slash DD slash YYYY
Certifications:
Is the client a member of any organized clubs?
- Yes
- No
If yes, provide name(s):
Average dive depths:
Deepest dive:
How often does the client dive this deep?
Dive location(s):
How often does the client dive per year?
Number of Dives During the Past 12 Months
Less than 50 feet Average time per dive
Number of Dives During the Past 12 Months
50 - 100 feet Average time per dive
Number of Dives During the Past 12 Months
101 - 150 feet Average time per dive
Number of Dives During the Past 12 Months
Greater than 150 feet Average time per dive
Number of Dives Contemplated in the next 12 Months
Less than 50 feet Average time per dive
Number of Dives Contemplated in the next 12 Months
50 - 100 feet Average time per dive
Number of Dives Contemplated in the next 12 Months
101 - 150 feet Average time per dive
Number of Dives Contemplated in the next 12 Months
Greater than 150 feet Average time per dive
For Insurance Professional Use Only — not intended for use in solicitation of sales to the public. Products and programs offered through Tellus are not approved for use in all states. 07.06.17. Copyright © 2017 Tellus Brokerage Connections

Scuba

Scuba Questionnaire