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 MM slash DD slash YYYY Client Name Date of Birth MM slash DD slash YYYY Gender Male Female Face AmountMax Premium $/yearTypeTermPermanentHas 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 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 Δ