Scuba QuestionnairePlease answer all questions applicable to the client's medical history. Questions? Call Jim or Teresa at 877.564.1707. Producer Name*Phone*Email* Date Date Format: MM slash DD slash YYYY Client NameDate of Birth Date Format: MM slash DD slash YYYY GenderMaleFemaleFace AmountMax Premium $/yearTypeTermPermanentHas the client ever used any form of tobacco (cigarettes, cigars, pipe, snuff, etc)?YesNoFrequencyDate of Last UseType 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 divingWreck divingSalvage divingIf any are selected, provide details: Type of equipment used: Does the client ever dive alone? Yes No Date of last dive: Date Format: MM slash DD slash YYYY Certifications: Is the client a member of any organized clubs?YesNoIf 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 MonthsLess than 50 feetAverage time per diveNumber of Dives During the Past 12 Months50 - 100 feetAverage time per diveNumber of Dives During the Past 12 Months101 - 150 feetAverage time per diveNumber of Dives During the Past 12 MonthsGreater than 150 feetAverage time per dive Number of Dives Contemplated in the next 12 MonthsLess than 50 feetAverage time per diveNumber of Dives Contemplated in the next 12 Months50 - 100 feetAverage time per diveNumber of Dives Contemplated in the next 12 Months101 - 150 feetAverage time per diveNumber of Dives Contemplated in the next 12 MonthsGreater than 150 feetAverage 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