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Scuba Diving Questionnaire

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Scuba Diving Questionnaire Powered By Docstoc
					                                                                                         SCUBA DIVING
                                                                                        QUESTIONNAIRE                                                         5000 Yonge Street
                                                                         (to be completed by Proposed Life Insured)                                     Toronto, ON M2N 7J8




Name_____________________________________________________ Date of Birth _________________________ Policy # ________________________
                                   Proposed Life Insured                                               Day            Month             Year                     Head Office Use

1.                                     Indicate all type of diving activities you participate in by completing the appropriate blocks below
      Types of Dives:           Recreational             Salvage                Professional           Commercial/Occupational
      Are you currently certified by:           PADI             NAUI               ACUC            YMCA               NACD              NSSCDS
                                                                                 Number of Dives                      Average time under water per Dive               Number of Dives
                           Depth of Dive
                                                                     Lifetime      Last 12 Months Next 12 Months      Lifetime     Last 12 Months Next 12 Months Expected Next 12 Months
      Diving or Submerging
      To 60 feet or less
      To 100 feet
      To 150 feet
      To 200 feet

2. Level of certification:        Basic         Open Water           Advanced Open Water              Master Diver           Dive Master          Assistant Instructor          Instructor
     Other (explains): ______________________________________________________________________________________________________________
     Date of last certification: ________________________________________________________________________________________________________
3. Specialty Certification:          Rescue           Medic First Aid            Search & Recovery            Night Diver          Deep Diver           Wreck Diver            Cave Diver
     Other (explains): ______________________________________________________________________________________________________________
     Date of last certification: ________________________________________________________________________________________________________
4. Equipment used:              Mask           Snorkel            Fins            Regulator         Octopus            Air Pressure Gauge               Depth Gauge               Compass
        Buoyancy Compensator                Weight Belt           Wet Suit            Dry Suit         Water Temperature Gauge                 Knife        Gloves
     Other (please state): ___________________________________________________________________________________________________________
5. Usual dive sites:           Ocean           Lake         River          Gravel Quarry
     Other: ______________________________________________________________________________________________________________________
6. Purpose for diving:            Recreation           Photography               Scientific       Hunting
     Other (please state): ___________________________________________________________________________________________________________
7. Average depths: __________________________ Deepest and how often: ________________________________________________________________
8. Decompression dives:                                                                                                                                                     Yes         No
     If “Yes”, maximum depths __________________ maximum bottom times:________________________________________________________________
9. Date of last dive: ________________________________________________ Total dives to date: ______________________________________________
10.Do you dive alone?                                                                                                                                                       Yes         No
     If “Yes”, please explain:_________________________________________________________________________________________________________
     ___________________________________________________________________________________________________________________________
11.Other Comments: _____________________________________________________________________________________________________________
     ___________________________________________________________________________________________________________________________
     ___________________________________________________________________________________________________________________________
I understand that my answers to the above questions will be relied on by Transamerica Life Canada in establishing my premium rate. If the above answers are not true, complete and correctly
recorded, any policy issued as a result of this questionnaire (being part of the Application for Life Insurance) may be rendered void on the grounds of misrepresentation or fraud.
I hereby declare that I have read all the questions and answers in this questionnaire and the statements and answers given above are true, complete and correctly recorded to the best of my
knowledge and belief. I understand and agree that this questionnaire shall form part of my Life Insurance Application to Transamerica Life Canada.

Dated at _____________________________________________ this _______________ day of _____________________________________ 20 ________

_____________________________________________________________                                    _____________________________________________________________
                 Signature of Proposed Life Insured                                                                    Signature of Witness


                                                                                                                                                                  UW-SCUQ395 11/06

				
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