PROFESSIONAL LIABILITY INSURANCE 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.
 
     
  Exclusively for PADI Professional 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

 

Step 1: Personal Information
 
New (Not currently insured with V&B) Renewal (Currently insured with V&B)
 
! GROUP PROFESSIONAL LIABILITY APPLICANTS MUST COMPLETE THE PDF APPLICATION !
           
PADI #:        
First Name: Initial: Last Name:
   
Mailing Address:
Address:
 
City:     State/Province:
Zip Code:     Country:
 
Physical Address (If different than the mailing address):
 
 
Home Phone:     Mobile Phone:
FAX:        
E-Mail:
E-Mail 2:
  (Your certificate may be e-mailed to you from instructors@diveinsurance.com.  Please make sure you add this to your safe senders list.)
           
 

Step 2: Coverage and Options

Premium Fully Earned 1

Select a Policy Period    
       
June 30, 2016 - June 30, 2017    
August 1, 2016 - June 30, 2017    
September 1, 2016 - June 30, 2017    
October 1, 2016 - June 30, 2017    
November 1, 2016 - June 30, 2017    
December 1, 2016 - June 30, 2017    
January 1, 2017 - June 30, 2017    
February 1, 2017 - June 30, 2017    
March 1, 2017 - June 30, 2017    
April 1, 2017 - June 30, 2017    
May 1, 2017 - June 30, 2017    
June 1, 2017 - June 30, 2017    
       
Select your Coverage and Options
 
Instructor

$0.00

Assistant Instructor
Divemaster
Nonteaching/Supervisory Instructor (4)
Divemaster/Assistant Instructor Assisting Only (2)
Freediver Instructor
TecRec Instructor (5)(6)
TecRec Assistant Instructor (5)(6)
TecRec Divemaster (5)(6)
TecRec Nonteaching/Supervisory Instructor (5)(6)
TecRec Divemaster/Assistant Instructor Assisting Only (2) (5)(6)
International Instructor (3)
International Assistant Instructor (3)
International Divemaster (3)
International Nonteaching/Supervisory Instructor (3)(4)
International Divemaster/Assistant Instructor Assisting Only (2) (3)
Not Selected

ScubaFit Instructor (7)

$0.00

ScubaFit Instructor - Declined

Cylinder Inspector

$0.00

Cylinder Instructor
Cylinder Inspector & Instructor
Cylinder Inspector Or Instructor - Declined

Equipment Liability Coverage
(Liability coverage for personally owned sets of scuba equipment used for instruction AND/OR when supervising certified divers)

$0.00

Equipment Liability Coverage - Declined

Excess Liability Coverage ($9,000,000)

$0.00

Excess Liability Coverage ($4,000,000)
Excess Liability Coverage ($3,000,000)
Excess Liability Coverage ($2,000,000)
Excess Liability Coverage ($1,000,000)
Excess Liability Coverage - Declined
(Primary Limit $1,000,000)


Grand-Total: 

$0.00

 
 
Footnotes
The insurance costs include a premium, a $26 PADI Administration fee, plus applicable taxes and fees.
1 Premium fully earned means there is no refund if you cancel your insurance. This does not apply to the PADI Dive Store/Resort Instructional Policy.
2 Divemaster/Assistant Instructor Assisting Only option provides coverage to Divemasters and Assistant Instructors ONLY while assisting insured instructors with classes.
3 Available for non U.S. citizens teaching ONLY non U.S. citizens; not available in Australia, Canada, Japan, the Caribbean or U.S., it's territories and possessions.
4 No coverage will be afforded for any Open Water Scuba Instructor who teaches any form of scuba diving or snorkeling during the policy period.
5 Please fax or email a copy of your Technical Certification along with a copy of your confirmation notice to (714) 739-3188 or email instructors@diveinsurance.com.
6 Includes Recreational.
7 Please fax or email a copy of your Scuba Fit Certification along with a copy of your confirmation notice to (714) 739-3188 or email instructors@diveinsurance.com.
 
Step 3: In Lieu of Signature
 
By checking this box ...
I hereby declare that I have read, understand and accept the Exclusions included with this renewal. [Read Exclusions]
 
 
Step 4: Special Important Notice
 
READ CAREFULLY BEFORE COMPLETING

Insurance coverage is only provided if the insurance company is put on notice of a possible claim through one of its authorized agents or PADI.
 

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 except any matter already reported to PADI. 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 PADI 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 PADI, 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 PADI 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? In Training?
Yes   No Yes   No Yes   No Yes   No
Location of Incident:

Brief summary of situation or possible claim:

 

 

Step 5: 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

 
Step 6: 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: 
 
Please provide the following, if the Credit Card billing address is different than your address above:
Street Address or P.O. Box
Zip Code:

 

 

 
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

 
 

 

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License #: 0757776
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