Scuba

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22 Mill St. #410, Arlington, MA 02476, Voice 800 700-7505 Fax 781 643-2775

Scuba

Please complete the underwriting information questionnaire and any other medical impairment page necessary to properly underwrite your client.

* Mandatory Fields

Agents Info:

*Name:

Agency:

*Phone #: *Fax #:

*E-mail address:

Client Info:

*Name:

*DOB: *Height? *Weight?

*Sex?

If your client is a scuba diver, please answer the following:

1. Does your client participate in:

Please give details:

2. How often does your client dive?

3. What is the average depth of dives?

4. What is maximum dive depth?

5. Where does your client dive?

Please complete the Main Underwriting Worksheet and send it along with the this page or any other impairment page necessary to complete underwriting.