Home Contact Privacy Policy
 

 

 EMERGENCY FIRST RESPONSE
PROFESSIONAL LIABILITY - APPLICATION		  

 

  Policy Period is from 12:01 AM June 30, 2018 through 12:01 AM June 30, 2019  
     
  APPLICATIONS MUST BE RECEIVED IN OUR OFFICE BY June 30, 2018.
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

efr@diveinsurance.com

  
PERSONAL INFORMATION

New / Renewal
EFR #: (Membership must be current for coverage to be effective)
First Name:  Initial:

Last Name: 
 
Mailing Address
Address 1:
Address 2:
City: State:
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, 2018		 After
Jan. 1, 2019		 After
Apr. 1, 2019

 

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, plus applicable taxes and fees.
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. I understand the premium is fully earned and no refund will be given if I cancel the policy.
   
 

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, 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
 
 

GDPR Agreement (This box must be checked)

By checking this box...

HUB International Insurance will use the information you provide on this form to be in touch with you and to provide updates and marketing. We will treat your information with respect. For more information about our privacy practices please visit our website. By checking this box, you agree that we may process your information in accordance with these terms.
  
 
 

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.
The information herein is for illustration purposes only and is designed as a general description of coverage's. Coverage will be determined by the actual policy language.