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COVID-19 Exposure Questionnaire Form

The document is a COVID-19 exposure questionnaire for a life insurance application. It asks if the applicant or family members have traveled abroad in the last 21 days or plan to in the next 3 months. It also asks if the applicant or family have any COVID-19 symptoms, have tested positive, been quarantined, or have an occupation with close contact to COVID-19 patients. The applicant declares the information is true.

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Pratik Mukul
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66 views1 page

COVID-19 Exposure Questionnaire Form

The document is a COVID-19 exposure questionnaire for a life insurance application. It asks if the applicant or family members have traveled abroad in the last 21 days or plan to in the next 3 months. It also asks if the applicant or family have any COVID-19 symptoms, have tested positive, been quarantined, or have an occupation with close contact to COVID-19 patients. The applicant declares the information is true.

Uploaded by

Pratik Mukul
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

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

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