Professional Underwater Liability Insurance Application

* Desired Effective Date:
New    Renew
 
* Association #:
 
* First Name: Initial:
* Last Name:
 
* Address 1:
  Address 2:
* City:
  State/Province:
  Zip Code:
* Country:
 
* Home Phone: Work Phone:
 
 
  FAX:
* E-mail:
 

Section 1 - Professional Liability Insurance - Base Premium

Select category based on the desired coverage limit. Insurance costs include premium, fees and applicable State taxes. All costs are in US funds and are fully earned - there are no refunds. Higher limits are available by individual quotation - contact Peter Meyer or Barb Beauchemin

Limit per Occurence $1,000,000 $2,000,000 $3,000,000
Active Instructor $499.00 US $840.00 US $985.00 US
 
Divemaster $290.00 US $485.00 US $565.00 US
 
Assistant Instructor $290.00 US $485.00 US $565.00 US
 
Sustaining Instructor $290.00 US $485.00 US $565.00 US
 
Retired Intructor $185.00 US $300.00 US $350.00 US
 
 

Section 2 - Optional Coverage

Select Optional Coverage(s) required:

Technical Training/Supervision
(you must be "tech" certified for this coverage to apply)
Your policy can be extended to provide coverage for qualified individuals conducting activities that exceed normal SDI/TDI/ERDI parameters.

Choose Tech A OR Tech B Option NOT Both
Technical Endorsement A | 33.00
Adds coverage for Training / Supervision deeper than 130 feet / 40 metres and for gas mixes other than Air or Nitrox (I.E. Tri-mix).

Technical Endorsement B | 65.00
Adds Tech Endorsement A plus coverage for Training / Supervision with rebreathers (SCCR and / or CCR).

Equipment Liability | 225.00
Your policy can be extended to provide liability coverage for equipment failure. This coverage extension applies only to equipment owned by the insured and used in the insured's classes under his/her supervision.

 
 

Section 3 - Other Associations

Indicate all other training agencies you have "Active" status with and we will provide them with proof of Coverage and list them as "additional insured" on your policy. You must be in "Active" status with the associations you check below...

Coverage to apply:

NAUI IANTD ACUC NACD PSA SDI
TDI SSI NASE ANDI MDEA BSAC
CMAS PADI RAID UTD SEI PDIC
GUE
 

Section 4 - Additional Insured

You can add "additional insureds" at no charge, but do not normally need to - Dive shops, Vessel Owners etc., are already added and do not need to be listed. If you have facilities that insist on formal proof, you can list their legal names below and we will formally add them to your policy.

Legal Name 1:   Relationship:
Legal Name 2:   Relationship:
Legal Name 3:   Relationship:
Legal Name 4:   Relationship:
Legal Name 5:   Relationship:
Legal Name 6:   Relationship:
Legal Name 7:   Relationship:
Legal Name 8:   Relationship:
Legal Name 9:   Relationship:
Legal Name 10:   Relationship:
 

Warranties

 

Section 5 - Acceptance of Terms

By checking this box...

I hereby declare that I have read, understand and accept the Terms, Conditions, Limitations and Warranties as printed on this application. I also declare that I have not been declined professional liability insurance from other similar programs and that I have not been suspended, annulled or removed from any other instructor association or agency. I hereby agree that any false statement made on this application will result in the coverage applied for being considered null and void from inception. In that event any premium paid will be returned.

Note: This is a claims made form of insurance. If you have knowledge of prior incidents, accidents, acts, errors or omissions that may lead to legal action or claim for your instructional and/or supervision activities, you must immediately submit a completed accident report to your previous insurance carrier. If this is a renewal of current coverage, you may forward any accident report for the prior term of insurance directly to Willis Insurance at PMB 712, 250 H Street, Blaine, WA 98230- 4033 or Willis Canada Inc at 1500 -- 1095 West Pender St. Vancouver, BC V6E 2M6.
 

Section 6 - Total Premium Information

Total Premium: $0.00