COVID-19 (Coronavirus) Exposure Questionnaire

Life assured’s Name : Pratik Mukul Application Number: 451980009

Travel Declaration Answers Details

Date of
Yes No Country travel Duration
Have you or your close family members travelled abroad in
1 the past 21 days? No
2 Do you intend to travel abroad in next 3 months? No

Covid-19 exposure Declaration Yes No Details

Are you or any of your family members currently suffering/
or have in the last 21 days, suffered from fever, cough, sore
throat, flu like symptoms, gastrointestinal symptoms? If yes
1 what was the diagnosis and treatment taken No
Have you or your family members have been tested positive
for novel coronavirus or advised to be tested to rule out the
2 diagnosis of the same? No
Have you served a notice of quarantine or come in close
3 contact with anyone who has been quarantined? No
Does your occupation involve any duties where you need to
be in close contact with Covid 19 diagnosed or quarantined
4 patients? No

Declaration
I agree that this form will constitute part of my application for insurance(s) and that failure to disclose
any material fact known to me may invalidate my insurance(s).
Date : 06th June 2020
Place : Hyderabad

Applicant Signature