DIVE STORE/RESORT INSURANCE APPLICATION  

 

  Policy Period is from 12:01 AM June 30, 2017 through 12:01 AM June 30, 2018  
     
  APPLICATIONS MUST BE RECEIVED IN OUR OFFICE BY JUNE 30, 2017.
THERE IS NO GRACE PERIOD.
ALL OTHERS WILL BE EFFECTIVE THE DATE RECEIVED.
 
     
  Exclusively for PADI Dive Center and Resort Members  
     
  Underwritten by a U.S. Rated A++ XV Insurer  
 

CONTACT US!

 
 

Have questions?
Call us at
1 800 223 9998
or
1 714 739 3177

FAX us at
1 714 739 3188

 

BUSINESS INFORMATION

 
Requested Policy Period, from:   To 06/30/2018   (MM/DD/YYYY)
Application Type: New        Renewal
PADI DiveCenter/Resort No.
Legal Business Name:
DBA:
Corporation 
  Who are the shareholders?
Partnership
  Who are the partners?
Sole Proprietor   
Other, please explain:

Mailing Address

Address 1:
Address 2:
City: State/Province:
Country: Zip Code:
Physical Address (If different than the mailing address):

 
Phone: FAX:
E-Mail 1:
E-Mail 2:
Web Site:
 

PROPERTY INFORMATION (Available in U.S. and its territories only)

   
Building Construction:     Wood Frame  Masonry  Concrete 

Central Station Alarm:

Yes  No

(Burglary coverage is afforded only with a working central station alarm)

Fire Sprinklers:     Yes  No
Distance from Ocean/Gulf:
 

Please indicate the amount of insurance required for each category below. The amount should include the replacement value for items as store displays, fixtures, computers, furniture, equipment and tools (including rental equipment), property of others (employee scuba equipment stored on premises, customer repair equipment, etc.) and tenant improvements. Inventory value should be reported at your cost. PADI Members with multiple locations should include the contents for each category for all locations.

 
Furniture, fixtures and equipment:
(Do Not include a Dollar sign or comma's. Example: 7000.00)
  $
Inventory/Stock:
(Do Not include a Dollar sign or comma's. Example: 7000.00)
  $
Property of others:
(Do Not include a Dollar sign or comma's. Example: 7000.00)
  $
Signs (Attached or Detached):
(Do Not include a Dollar sign or comma's. Example: 7000.00)
  $
Tenant Improvements:
(Do Not include a Dollar sign or comma's. Example: 7000.00)
  $
Other:
(Do Not include a Dollar sign or comma's. Example: 7000.00)
  $
Do you own property, including compressors, off premises:   $

Please explain location: 


Total:   

 

Do you own the building?

  Yes  No

  If yes, what is the replacement value?   $
  Year built?     
What is the square footage of your building?     
Updates on plumbing, electrical, roof, etc.

PROPERTY DEDUCTIBLES
Property Deductible: $1,000  $2,500  $5,000
Deductible for Mechanical Breakdown is $2,500 and Wind/Hail is 5%
 

GENERAL LIABILITY INFORMATION

   
Estimated 12 month retail receipts
(Except Instructional/Supervisory & Travel Receipts):

  $

(This should include all of your dive-related business. PADI Members with multiple locations should include the total receipts for all locations.)

Do you have a pool on premises?

Yes  No

     If yes, is it used for activities other than diving and/or swimming?
     
(If yes, contact Vicencia & Buckley for supplemental form)

Yes  No

 
Do you have any incidental locations, i.e. office, kiosk, etc? Yes  No
     If yes, please describe here:                                    

You will need to complete another application for these locations.

Do you have property at that location to be insured? Yes  No
     If yes, please enter the value to insure:  $

You will need to complete another application for these locations.

 
Do you conduct recreational or business activities, other than diving, at your facility? Yes  No
     If yes, please check all that apply below
  Cylinder hydrostatic testing
  Other equipment sales, please explain:
  Other equipment repairs, please explain:
  Other equipment rentals, please explain:

  Other business activity, please explain:

 

CLAIMS INFORMATION

   
Have you had any store property (fire, theft, burglary, theft, etc.) or liability (slip & fall, other in-store liability) claims in the last five (5) years? Yes  No
     If yes, please list the date of the claim, the amount paid and any amounts outstanding:

Previous Insurance Company
 

OPTIONAL COVERAGE'S

Travel Agent E&O

Receipts:

     
  NON-Owned Auto Liability (U.S. Only) No  100K  1M
     
Additional Loss of Business Income - Enter amount over $40,000
($40,000 included in standard policy)

   $ 

   

 

 

Lake, quarry, pond
(Contact Vicencia & Buckley for supplemental form)

Acreage:

       
Excess Liability Coverage (Primary limit $1,000,000) No  1M  2M  3M  4M 9M
       
Do you want a quote from the National Flood Insurance Program?

  

       

 

STORE/RESORT INSTRUCTIONAL POLICY

 

PADI Dive Centers and Resorts are able to secure professional liability insurance for the dive professionals who provide professional services for the store at reduced prices. Discount rates are computed according to the gross receipts for instructional and supervisory activities. PADI Members with multiple locations should include the receipts for all facilities.

   
Annual Estimated Scuba/Snorkeling/Swimming/Instructional/Supervisory Receipts:    $ 
Annual Estimated Emergency First Response Instructional Receipts:     $ 
Number of Instructors:

Divemaster/Assistant Instructors:

 

Statement of Understanding (This box must be checked)

Person Completing this application
Name :  Title : 
By checking this box ...
We (I) know and acknowledge that this policy does not provide any insurance coverage or defense for snow-ski rentals or snow-ski binding adjustments. No coverage is provided for firearms (this exclusion does not include spear guns). No coverage is provided under this policy for any professional liability except under the terms of the Contingent Professional Liability coverage. Professional Liability includes, but is not limited to, instruction of scuba diving and snorkeling or other forms of aquatic activity. The policy defines these and other exclusions as they apply. Burglary Coverage is afforded only with a working Central Station Alarm (Policy Warranty and applies only when property coverage is purchased). This policy does not provide coverage for Workers Compensation, Employers Liability, Employment Practices Liability, motorized watercraft or non motorized watercraft more than 20 feet in length.
 

ADDITIONAL INSUREDS

   

1.

Employees are automatically covered under your store or resort operator's policy (does not include Professional Liability).
2. Divemasters and Instructors may not be added as additional insureds.
3. Owners, officers and directors of your business are automatically covered under your policy and need not be added as additional insureds (does not include Professional Liability).

No charge for Additional Insureds.

  As per existing policy (if renewing)
New list of Additional Insureds.
No Additional Insureds
Information for each Additional Insured is required as follows:
Name Address City State Zip Business Relationship

 

ADDITIONAL LOCATIONS

Information for each Additional Location is required as follows:
You will need to complete another application for these locations.
Name Address City State Zip
 

PAYMENT INFORMATION

 

Upon receipt and review of the completed application, Vicencia & Buckley, a division of HUB International will provide your with a total premium for your approval before coverage is placed. Upon your acceptance of the policy and premium, credit card information can be provided to Vicencia & Buckley, a division of HUB International or a check/money order mailed. Premium Financing is also available.

 

COMMENTS

 
 

 

 
License #: 0757776
Copyright Vicencia & Buckley, A Division of HUB International Insurance Services, Inc.