COVID-19 (Coronavirus) Exposure Questionnaire

Thank you for applying for a policy from Max Life Insurance Company Limited. To enable us to assess your application, send this
questionnaire duly answered and signed by the Life to be Assured and Proposed Policy Holder, if any.
(All questions to be acknowledged, sections which are not relevant should be mentioned NA (Not applicable)
Application No.
Name of Life to be Assured
Name of Proposed Policyholder
(if different from Life to be Assured)

Yes No
If YES,
1. Have you or your family member(s) traveled abroad since
01/01/2020? Mention name of the country/countries travelled to

Date of return:

Yes No

If YES, mention name of the country/ countries

2. Do you intend to travel abroad within the next 6 months?
Intended date of travel:
Duration of stay:

Yes No
3. In the last 3 months, are you currently or your family If YES, mention details: tick appropriately
member(s) suffering from or have suffered from -flu like
symptoms, fever, sore throat, runny nose, persistent cough, Self Family Member
sore throat, shortness of breath, breathing difficulties, Exact diagnosis:
malaise, gastro-intestinal symptoms such as nausea,
vomiting, diarrhea, advised to undergo test or awaiting test Date of diagnosis:
results for SARS-CoV-2/COVID-19*? Recovery (tick appropriately Yes NO
Date of Recovery

Yes No
If YES, mention details:
Date of positive diagnosis for SARS-CoV-2/COVID-
19* (please mention NA if not applicable) -

Specify the name of test done: (please mention NA

if not applicable) -

4. Have you had direct contact with someone who has

been confirmed or is suspected to SARS-CoV-2/COVID- Details of subsequent tests (please mention NA if
19* positive? not applicable)
Did you require admission to hospital? Yes No
Or

Have you Tested positive for the novel coronavirus If YES, mention did you require stay in:
(SARS-CoV-2/COVID-19)?
O High-dependency unit (HDU)
O intensive care unit (ICU)
O intensive treatment unit (ITU)
O critical care unit (CCU)
O Others
Support of a ventilator
Yes No
 Have you made a full physical function recovery, able to
perform your normal occupational or daily duties, without
any ongoing symptoms or restrictions (i.e. shortness of
breath or fatigue)?
Yes NO

Date of Recovery

Yes No
5. Are you serving a notice of quarantine in any form imposed by If YES, mention details:
local health authorities or government or airport authority for
Location:
possible exposure to novel coronavirus (SARS- CoV2/COVID-
19)? Quarantine period: From DD/MM/YYYY to
DD/MM/YYYY

If answer to Question 3 - 5 is yes please provide all related prescriptions, records and medical reports

COVID-19 (Coronavirus) Exposure Questionnaire for Health Care Workers 1

1. Occupation

2. Medical Specialty (if applicable)

3. Exact nature of duties (including procedural or non-procedural
duties)
4. Name and address of the healthcare facility or facilities in which
you work.
5. Name of the Health Authority under which you are registered.
Yes NO
6. Does your healthcare facility have sufficient personal protective
equipment (PPE) to provide to its workforce?

Yes No
7. Have you been or do your work duties involve close contact
with anyone who has been quarantined or who has been If yes, please provide details including nature of work for
diagnosed with novel coronavirus (SARS-CoV-2/COVID-19)? patients with novel coronavirus (SARS-CoV-2/COVID-19)

8. Have you ever been on voluntary leave, or placed on Yes No

compulsory leave of absence/sick leave, due to a possible
If yes, please provide relevant period/dates
exposure to novel coronavirus (SARS-CoV-2/COVID-19)?
and details

Yes No
9. Are you currently in good health? If No, please share
details

I hereby declare and agree that the above particulars and answers are complete and true, that I have not held back any relevant
facts or details, and that the answers to questionnaire will form part of the application for the desired insurance on my life.

Date / /

1
Health care Workers shall mean all registered health care professionals (doctors, nurses, allied health professionals including
physiotherapists, pharmacists, phlebotomists etc.) involved in direct patient care