Affiliated Center Registration Application for
SCUBA MEDIC DIVING ASSISTANCE

Center Information

Date*

Company/Self-employed Name*

Center Commercial Name

Tax ID/ID Number*

Address*

City*

Postal Code*

Province/State

Website

Phone*

Email*

Full Name*

Do you have liability insurance contracted with us as a dive center/school/instructor? *

Yes

During the first days of each month, you must review the invoice directly on the insurance website for policies issued during the previous month.
Payment will be charged to your bank account within the first 5 days of each month.
In case of a bank return, the system will close access until payment is made by sending us a copy of the payment receipt.
Any bank account change must be communicated before the end of the month to our email: admin@segursub.com
It is mandatory to provide the insured person's email on the insurance policies. Through this email, the insurance documentation, policy conditions, and emergency phone numbers will be sent. In case of a diving accident, the insurer will contact the injured party for quick claims processing. Using the center's or school's email is not acceptable.

I hereby accept that the monthly receipts from Consultores Segursub S.L. will be charged to the bank account described below.

Account Holder*

Bank Name

IBAN*

I accept the terms and conditions stated in this application *