DAN Individual Application

Form
Name*

Legal First NameLegal Last Name
Date or Birth*

DayMonthYear
Date
Dive Operator/Center Name*
Swimming/Lifeguarding InstructorScuba InstructorScuba Instructor in TrainingAssistant Scuba InstructorDivemasterDivemaster in TrainingSkin DivingSkin Diving InstructorFreedive InstructorRetired (inactive) Scuba InstructorRetired DivemasterAssistant Instructor (Tail Coverage)
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
Technical Dive TrainingRebreather
Rebreather Manufacturer Name
Rebreather Model
Rebreather Certification Number
Rebreather Training Agency
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
YesNo
If yes, how can DAN Services obtain a copy?*
YesNo
YesNo
YesNo
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)*
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.I understand that failure to disclose any material facts, which would be likely to influence the acceptance and assessment of theApplication, may result in the Underwriters refusing to provide indemnity or cancelling the policy in every respectI hereby agree and accept that this Declaration and the other parts of this Application shall be the basis of the contract betweenboth parties if entered into and shall become a part of the contract of insurance.I hereby agree and accept that this is a Claims Made policy and that I am required to provide immediate written notice to the partydesignated in the policy of any incident, accident, occurrence, act, error, or omission that might lead to a claim, and that failure toprovide such written notice may result in a denial of coverage under the policy.I hereby acknowledge and declare that I have never had my membership or credentials suspended, annulled or removed by anydive instructor association or training agency and I understand that coverage will only be effective as long as my professionalmembership is current or I am in training with a recognized dive instructor association or training agency.I acknowledge and accept that this coverage is provided by DAN Risk Retention Group, INC. and understand that the carrieris not required to be licensed in our State of domicile, but is allow to do business in our State on a non-admitted andunlicensed basis.I hereby acknowledge and declare that I have never been declined professional liability insurance, have never had a policycancelled or non-renewed, and have never had special terms imposed.I acknowledge and accept that I am covered only for incidents/claims that arise from providing Professional Services I provide onbehalf of the Named Insured.I acknowledge and declare that I have read, understand and accept the Fraud Warning as set forth on page 6 of the Application.I acknowledge and declare that I have read, understand and accept the Exclusions as set forth on page 7–14 of the Application.
Signature*
Date*

DayMonthYear
Date
Should be Empty:

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