Impaired Risk Questionnaire For Scuba Diving



Scuba Diving

Scuba Diving involves impaired risk underwriting, where a person whose physical condition is less than standard or
who has a hazardous occupation or hobby, to help obtain the best tentative offers by several top rated life insurance companies.

Please submit a completed form below to shop for the best possible premium:

* required information       **Please use TAB key to proceed to the next question field, not the ENTER key.**

Agent's Name*:
Phone Number*:
E-Mail Address*:
Applicant's   Date Of Birth:
Sex: Male Female
Death Benefit:
Type of Product: Term Universal Whole Life
Second to Die Variable
Has your client ever used tobacco or nicotine products? Yes No

If yes, what type of product did you use? (Select all that apply)
Cigarettes Cigar Pipe Other
2. Does your client engage in recreational or commercial diving? Yes No
3. How often does your client dive and what is the average depth of his/her dives?
4. What is your client's maximum dive depth?
How many dives at the maximum depth?
Where does your client dive?
5. Additional Comments?