Ask the Doctor – SCUBA

Obtain a tentative offer for a case involving Scuba Diving by completing the form below:

* required information

**Please use TAB key to proceed to the next question field, not the ENTER key.**

1. *Agent Name :
*Address :
*City :
*State :
*Zip :
Agent E-Mail:
Agent Phone :
2. Applicant’s Name:
Date Of Birth:
Sex:	Male Female
Height:
Weight:
Occupation:
Death Benefit:
Type of Product:	Term Universal Whole Life
	Second to Die Variable
Have you ever used tobacco or nicotine products?	Yes No If yes, what type of product did you use? (Select all that apply) Cigarettes Cigar Pipe Other
3. Do you engage in recreational or commercial diving?	Yes No
4. How often do you dive and what is the average depth of your dives?
5. What is your maximum dive depth?
How many dives at the maximum depth?
Where do you dive?
6. Additional Comments?