Online Application Form

SCUBA Instruction Services Short Form Application

Per Claim Limit	Aggregate Limit	Abuse & Misconduct	Retention	Premium
$1,000,000	$3,000,000	$10,000 sublimit	$0	$625

Complete legal entity name and dba of the Applicant:

Principal Business Address:

Do you own this location?:

Additional Business Addresses:

Years in operation:

Phone:

Email:

Website URL:

If current Professional Liability coverage is in force for these activities please specify:

Carrier:

Expiration Date:

Limits:

Retroactive Date:

I am an individual currently certified as a SCUBA instructor for the agency below seeking professional liability insurance for SCUBA instruction services only

As part of my instruction services, I ensure that

a Liability Release and Assumption of Risk & Medical Statement form are completed by all students prior to instruction
an Acknowledgment of Safe Diving Practices form is completed by all students after training but prior to certification
an incident report form is completed when necessary in accordance with my training agency’s (listed above) instructor’s manual
legal guardians read and sign my training agency's Parental responsibility for Minor Divers form prior to instructing a minor
I provide direct or indirect supervision, as required, at all times

I understand that Professional Liability coverage does not extend to products liability, and if I have any retail operations, those are covered by a separate General Liability policy including products liabilty.

I do NOT have current knowledge of any incident or circumstance that could reasonably be expected to give rise to a claim under the proposed insurance coverage.

I have NOT had any prior professional liability claims made against me

In lieu of signature, I warrant that all statements in this application have been truthfully answered and we have not misstated any material fact and understand that this application shall be the basis of the contract with the insurance carrier.

Additional Comments:

Scubalife Membership No.:

Full Name:

Title:

Date: