Instructor Insurance Form - Portage Quarry

Portage Quarry Dive Instructors, Assistant Instructors
and Dive Masters Application and Insurance Information

Instructor Insurance Verification

Please ensure we have this information updated for 2008 before training begins. Also see insurance notice below.

Portage Quarry Recreation Center, Inc.

Apply below or click here for a PDF Paper Application

First Name:
Last Name:
Street Address:
City:
State/Province:	Zip:
Phone:
Birth Date:	Instructor No:
Which Agency:	Other:
eMail:
Your Dive Center/ Store Affiliation:
Insurance Policy Name:
Policy Number:

Important Notice: Portage Quarry is also requiring a 2008 current copy of your insurance policy to have on file with the following entity named as an additional insured on the individual�s instructor liability insurance policy.

Portage Quarry Recreation Center Inc.
12701 South Dixie Highway
Bowling Green Ohio, 43402
419-352-9203

Instructors dive for free when they are with students and teaching a class.