EMERGENCY FIRST RESPONSE
PROFESSIONAL LIABILITY
- APPLICATION
 

 

  Policy Period is from 12:01 AM June 30, 2016 through 12:01 AM June 30, 2017  
     
  APPLICATIONS MUST BE RECEIVED IN OUR OFFICE BY June 30, 2016.
THERE IS NO GRACE PERIOD.
ALL OTHERS WILL BE EFFECTIVE THE DATE RECEIVED.
 
     
  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

 

PERSONAL INFORMATION

New / Renewal

EFR #:
First Name:  Initial:

Last Name: 
 
Mailing Address
Address 1:
Address 2:
City: State/Province:
Zip Code: Country:
Physical Address (If different than the mailing address):
 
Home Phone: Mobile Phone:
FAX:    
E-Mail:
E-Mail (Alt):
   
 

SELECT COVERAGE

 

PRO RATA PREMIUMS

Annual Fee After
Oct. 1, 2016
After
Jan. 1, 2017
After
Apr. 1, 2017

 

Select Coverage

Liability Coverage ($5,000,000)

$0.00

Liability Coverage ($4,000,000)
Liability Coverage ($2,000,000)
Liability Coverage ($1,000,000)
Not Selected

Grand-Total: 

$0.00

PREMIUM FULLY EARNED 1

The insurance costs include a premium, a $11 EFR administration fee, applicable state taxes.

1 Premium fully earned means there is no refund if you cancel your insurance.
   
 

IN LIEU OF SIGNATURE (This box must be checked)

By checking this box ...

I understand that this policy only covers my First Aid Training and does not cover any other professional activity including but not limited to instruction in or supervision of diving and snorkeling.

   
 

SPECIAL IMPORTANT NOTICE

READ CAREFULLY BEFORE COMPLETING. YOU COMPLETE ONLY 1 OR 2.
Insurance coverage is only provided if the insurance company is put on notice of a possible claim through one of its authorized agents or Emergency First Response.

Section 1 
By checking this box ...

I have no knowledge of any incident, accident, occurrence, act, error, or omission that might lead to, or has already lead to, a legal action or claim. I understand that I must report any incident, accident, occurrence, act, error, or omission to any previous insurer and that this policy does not cover any known incidents, accidents, occurrences, acts, errors, or omissions. By applying for this insurance, I hereby authorize Emergency First Response to release information to the insurance company pertinent to the investigation of insurance claims.
 

Section 2 
By checking this box ...

I have knowledge of an incident, accident, occurrence, act, error, or omission not previously reported to EFR, that might lead to a legal action or claim for my supervisory or instructional activities. I understand that I must report any incident, accident, occurrence, act, error, or omission to any previous insurer and that this policy does not cover any known incidents, accidents, occurrences, acts, errors, or omissions. By applying for this insurance, I hereby authorize EFR to release information to the insurance company pertinent to the investigation of insurance claims. 

Name of person injured:
Date of incident:

Explain how the report can be obtained:

Incident report filed? Fatality? Serious Injury?
Yes   No Yes   No Yes   No
Location of Incident:

Brief summary of situation or possible claim:

 

 

ADDITIONAL INSUREDS (No Charge)

   
1. No charge for Additional Insureds, however, all must be listed.
2. Entities other than those mentioned, when listed, will be reviewed by the insurance carrier; inclusion on your Certificate of Insurance will indicate that coverage is in effect.
3. List business relationship versus personal relationship; eg., "Bob Smith, property owner" not "Bob Smith, father".
4. Other Instructors and assistants may not be Additional Insureds but must obtain their own insurance.

 

  As per existing policy (if renewing) New list of Additional Insureds No Additional Insureds  
   

 

Information for each Additional Insured is required as follows or

Name

Address City State Zip Business Relationship

 

PAYMENT INFORMATION

 
Your Total is:

$0.00

 
  Not Selected AMEX MasterCard VISA
Payment Method:
Card Number:
(no spaces or dashes)
 
CVV2:  
Name on Card:    
Expiration Date:  Month:      Year: 
 
 
PADI  has made membership renewal simple.

Vicencia & Buckley is making AUTOMATIC RENEWAL for Professional Liability Insurance a reality!

   YES!  Sign me up for AUTOMATIC RENEWAL.
Click here for details

 
 

COMMENTS

 
 
 

If you click "Submit Application", your credit card will be charged for the amount shown above.
To avoid duplicate charges to your credit card, click "Submit Application" only once.

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