Form NF 57-03-07 NF 57-03-07 Verification of Liability Coverage

OMB Control Number: 0648-XXXX
Expiration Date: XX/XX/20XX

NOAA Form 57-03-07
(01-16)

U.S. DEPARTMENT OF COMMERCE
NATIONAL OCEANIC AND ATMOSPHERIC ADMINISTRATION

VERIFICATION OF LIABILITY COVERAGE
APPLICANT INFORMATION
CONTRACT DIVER NAME (Last, First MI)

NAME of EMPLOYER / CONTRACTOR

WORK ADDRESS

CITY

STATE

E-MAIL ADDRESS

PHONE NUMBER

FAX NUMBER

NOAA LINE or STAFF OFFICE and UNIT ASSIGNED

DIVE OPERATIONS START DATE

DIVE OPERATIONS END DATE

ZIP

The information below verifies that the above named individual is covered for costs associated with any dive
accident or other medical emergency that may occur during the course of his/her work at or with NOAA.
Instructions: Indicate below the type and extent of coverage, including, but not limited to; emergency
transportation (e.g. MEDEVAC), hyperbaric treatments, other medical treatments, hospitalization, and
compensation for lost wages associated with extended absence due to work-related medical emergencies (e.g.
worker’s compensation). Attach supporting information and documentation as necessary.
LIABILITY COVERAGE
TYPE and EXTENT of COVERAGE
INSURANCE COMPANY

POLICY START DATE
PHONE NUMBER

TYPE and EXTENT of COVERAGE
INSURANCE COMPANY

TYPE and EXTENT of COVERAGE
INSURANCE COMPANY

POLICY NUMBER

POLICY START DATE
PHONE NUMBER

POLICY END DATE

POLICY NUMBER

POLICY START DATE
PHONE NUMBER

POLICY END DATE

POLICY END DATE

POLICY NUMBER

COMMENTS

LIABILITY COVERAGE VERIFCATION
NAME and TITLE of COMPANY REPRESENTATIVE

COMPANY REPRESENTATIVE SIGNATURE

RESET

DATE

PRA Public Burden Statement
A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for
failure to comply with an information collection subject to the requirements of the Paperwork Reduction Act of 1995 unless the
information collection has a currently valid OMB Control Number. The approved OMB Control Number for this information
collection is 0648-XXXX. Without this approval, we could not conduct this information collection. Public reporting for this
information collection is estimated to be approximately 10 minutes per response, including the time for reviewing instructions,
searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the information collection.
All responses to this information collection are required to obtain benefits. Send comments regarding this burden estimate or any other
aspect of this information collection, including suggestions for reducing this burden to the NOAA Diving Center Executive Officer,
NOAA Diving Program, 7600 Sand Point Way NE, Building 8, Seattle, WA 98115, 206-526-6460.
Privacy Act Statement
Authority: The collection of this information is authorized under 29 CFR 1910, Subpart T, Commercial Diving Operations.
Additional authorities include 29 U.S.C. 653, 655, 657; 40 U.S.C. 333; 33 U.S.C. 941; Secretary of Labor's Order No. 8-76 (41 FR 25059),
9-83 (48 FR 35736), 1-90 (55 FR 9033), 6-96 (62 FR 111), 3-2000 (65 FR 50017), 5-2002 (67 FR 65008), 5-2007 (72 FR 31160), or 4-2010
(75 FR 55355) as applicable, and 29 CFR 1911.
Purpose: NOAA is collecting this information to assess an individual’s medical fitness to dive, proficiency, and further training.
Information will also be used to ensure diving equipment is safe and well maintained and that all policies are being adhered to for
safety reasons. Aggregate data is used for annual reports and other leadership documents.
Routine Uses: NOAA will use this information in the determination of an individual’s medical fitness to dive. Disclosure of this
information is permitted under the Privacy Act of 1974 (5 U.S.C. Section 552a) to be shared among Department staff for work-related
purposes. Disclosure of this information is also subject to all of the published routine uses as identified in the Privacy Act System of
Records Notice NOAA-10, NOAA Diving Program.
Disclosure: Furnishing this information is voluntary. However, the failure to provide complete and accurate information will exclude
the individual from NOAA’s Diving Program.