Professional Liability Insurance

First Name

Last Name

Date of Birthmm/dd/yyyy

DAN Member ID

Non-Member

Professional Status

Select Status...InstructorAssistant Instructor/Instructor in TrainingDivemaster/Divemaster in TrainingSkin Diving / Swimming InstructorRetired (inactive) InstructorRetired Divemaster/Skin Diving Instructor/ Assistant Instructor (Tail Coverage)

Previous Claims?

Select...No previous claims1 previous claim2 previous claims3 previous claims4 previous claims5 previous claims6 previous claims7 previous claims8 previous claims9 previous claims10 previous claimsMore than 10 previous claims

What activities do you currently participate in:

--Scuba Instruction

--Assistanting Scuba Instructors

--I'm an Instructor in Training

--Divemastering

--I'm a Divemaster in Training

--Skin Diving Instruction

--Free Diver Instruction

--Swimming Instruction

Contact Information

Mailing Address

City

State

select state...AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming----------Armed Forces EuropeArmed Forces AmericasArmed Forces Pacific

Zip/Postal Code

Country

United States

Email

Phone

Agency Affiliations

All agencies declared here will automatically be aded as Additional Insured on your final application.

Coverage Options

Effective Date

Select Start Date for Your Coverage

12:01AM ESTformat: mm/dd/yyyy

 

Coverage effective date begins at 12:01AM EST on the date selected. Coverage ends 1 year later at 12:01AM EST.