DAN Individual Application

Form
Name

Legal First NameLegal Last Name
Date or Birth

DayMonthYear
Date
Dive Operator/Center Name
Highest Level of Certification (swim teachers should indicate Swimming Instructor)
Training Agencies - please list all that apply (swim teachers should indicate SSI, please modify if SSI is not your primary training agency)
Training Agency ID# - please list all of them in order of agencies listed above
Home Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Personal DAN Member Number
OPTIONAL TRAINING MUST ALSO BE SELECTED BY POLICY OWNER FOR COVERAGE TO APPLY (skip if N/A)
Rebreather Manufacturer Name
Rebreather Model
Rebreather Certification Number
Rebreather Training Agency
Are you aware of any known claims or incidents that you are involved in?

Yes - Disclosure of Known Claim/Incident - I have knowledge of an incident, accident, occurrence, act, error, or omission (collectively "Event") not previously reported to DAN Services, Inc., that might lead to, or has already led to, a legal action or claim against the Applicant and I have disclosed such Event(s) below. Other than the Event(s) disclosed below and those previously reported to DAN Services, Inc., I have no knowledge of any other Event that might lead to, or has already led to, a legal action or claim against the Applicant. I understand that I must report any known Event to my previous insurer and that this policy does not cover any Event known on or before the effective date of this coverage. I also agree and understand that any Event which occurred prior to the effective date of this coverage which becomes a legal action or claim within 90 days of expiration of the previous policy must be reported and will be excluded under this policy. By applying for this insurance, I hereby authorize DAN Services, Inc. to release to the underwriters any information pertinent to the investigation of Event, legal action or claim.No - No Claims/Incident Declaration - I have no knowledge of any incident, accident, occurrence, act, error, or omission (collectively "Event") that might lead to, or has already led to, a legal action or claim except those matters already reported to DAN Services, Inc. I understand that I must report any known Event to my previous insurer and that this policy does not cover any Event known on or before the effective date of this coverage. I also agree and understand that any Event which occurred prior to the effective date of this coverage which becomes a legal action or claim within 90 days of expiration of the previous policy must be reported and will be excluded under this policy. By applying for this insurance, I hereby authorize DAN Service, Inc. to release to the underwriters any information pertinent to the investigation of any Event, legal action or claim.
First and Last Name of Applicant (no claims)
Today's Date (no claims)

MonthDayYear
Applicant's Signature (no claims)
First and Last Name of Applicant (professional with a claim/incident to disclose)
Today's Date (professional with a claim/incident to disclose)

MonthDayYear
Applicant's Signature (professional with a claim/incident to disclose)
Name of any person(s) injured in claim/incident
Name of Dive Professional(s) involved in claim/incident
Date of Incident

MonthDayYear
Date
Was an incident report filed?
If yes, how can DAN Services obtain a copy?
Fatality
Serious Injury
In Training
Amount of Loss (with defense cost)
Insurance Carrier
Location of Incident
Brief Summary of Incident
Applicant's Signature (professional with a claim/incident to discose)
Please confirm the following by checking the appropriate boxes:

I declare and warrant that I have read and understood the Application and that after full examination, all statements and particularscontained in the Application and any attachments are true and correct and that no information whatsoever has been withheldthat might increase the risk of the Underwriters or influence the acceptance of this Application and should the above particularschange in any way, I will advise the Underwriters immediatelyI declare and warrant that I have read and understand the Application and that after full examination, all statements and particularscontained in the Application and any attachments are true and correct and that no information whatsoever has been withheldthat might increase the risk of the Underwriters or influence the acceptance of this Application and should the above particularschange in any way, I will advise the Underwriters immediately.
Signature
Date

DayMonthYear
Date
Should be Empty:

Form