Full Application for Life Insurance

Pacific Life underwater diving

* Indicates required field

How long have you been diving *

What certifications do you hold? *

What kind of equipment do you use? *

What are the locations of your diving activities? *

Do you ever dive alone? If “Yes,” explain. *

Do you do any cave, wreck, or salvage diving? If “Yes,” explain. *

What are the average depths you dive? *

What are your deepest dives and how often? *

Do you dive for financial benefits? If “Yes,” explain. *

Are you a member of any organized clubs? If “Yes,” give name(s). *

How Many Dives 0-75 ft During Past 12 Months: Number of Dives & Average Time Per Dive? *

How Many Dives 0-75 ft Contemplated Next 12 Months: Number of Dives & Average Time Per Dive? *

How Many Dives 76-125 ft During Past 12 Months: Number of Dives & Average Time Per Dive? *

How Many Dives 76-125 ft Contemplated Next 12 Months: Number of Dives & Average Time Per Dive? *

How Many Dives 126-150 ft During Past 12 Months: Number of Dives & Average Time Per Dive? *

How Many Dives 126-150 ft Contemplated Next 12 Months: Number of Dives & Average Time Per Dive? *

How Many Dives Over 150 ft During Past 12 Months: Number of Dives & Average Time Per Dive? *

How Many Dives Over 150 ft Contemplated Next 12 Months: Number of Dives & Average Time Per Dive? *