COVID-19 (Coronavirus) Exposure Questionnaire

Name Of Proposed Insured : Varun More

Policy no: C264546876 Dated: 16-Apr-2022

Please answer the following questions in as much detail as possible:

1. Have you been in close contact with anyone who has been quarantined (including your family members)
or who has been diagnosed with novel coronavirus (SARS-CoV-2/COVID-19) within the last three Yes No
weeks?
• If yes, then please confirm if you had any COVID 19 symptoms?
2. Have you been advised to be tested to rule in or rule out, a diagnosis of novel coronavirus Yes No
(SARSCoV-2/COVID-19)?
• If yes, then please confirm status
Test Result Received Awaiting Test Results Not Yet Tested
If you have received the Test Result, it is mandatory answer to sub questions a and b
a. Date of Last COVID 19 result -
b. Result of Last COVID 19 test -
c. Did you require,
Admission to hospital Home Quarantine/Isolation Not Required
i. If Hospitalized:
- Date of Admission
- Date of Discharge
- Did you require treatment in the Intensive Care unit (ICU) and/or a machine Yes No
[ventilator support]to help you breathe?
- Did you experience any complication(s) related to lungs, Kidney, liver or heart problems(s)? Yes No
ii. If home quarantine / Isolation,
- Please specify the last date of home quarantine / Isolation -

3. If Question no 2 is answered as "Yes", then please answer below questions a and b"
a. Do you currently experience or did you had any recurrence of symptoms related to COVID 19 infection?
b. Do you have any pending or recommended follow-up appointments or tests related to COVID-19 Yes No
diagnosis? Yes No

4. Are you a Healthcare professional (Includes Doctors, Nurses, Pathologist, Paramedics, Pharmacist, Yes No
Ward helpers) & enrolled as Corona warrior or working in Hospitals/ Clinics with novel coronavirus
(SARS-CoV-2/COVID-19) ward/unit or treating/in contact with COVID-19 infected individuals?
 5. Travel Declaration
a. Have you travelled outside of India in the past 3 weeks? If Yes, please provide your travel details Yes No
over the past 3 weeks:
COUNTRY DATE ARRIVED DATE DEPARTED
b. Do you intend to travel Outside of India in next 3 months: If Yes, Please provide details of your Yes No
intended future travel within next 3 months:
COUNTRY DATE of TRAVEL INTENDED DURATION

6. Have you been vaccinated for COVID19?

Yes No
If yes , Please provide your details:
Date of administration of the first dose (Non-Mandatory)
Date of administration of the second dose (Non-Mandatory)
Have you experienced any adverse reaction post vaccination? Yes No

If yes, please share details including treatment taken for the same and date of complete recovery

Declaration
I confirm that the answers I have given are, to the best of my knowledge, true, and that I have not withheld any material
information that may influence the assessment or acceptance of this application.
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)
Signature of Varun More Date: 16-Apr-2022
Proposed insured
Signature of
Applicant:
(If applicant is different Date:
from the Proposed
insured)

Tata AIA Life Insurance Company Limited (IRDA of India Regn. No. 110) CIN - U66010MH2000PLC128403.
Registered Office & Corporate office: 14th Floor, Tower A, Peninsula Business Park, Senapati Bapat Marg, Lower
Parel,Mumbai - 400013. Trade logo displayed above belongs to Tata Sons Ltd and AIA Group Ltd. and is used by Tata AIA
Life Insurance Company Ltd under a license. For any information including cancellation, claims and complaints, please
contact our Insurance Advisor / Intermediary or visit Tata AIA Life's nearest branch office or call 1-860-266-9966 (local
charges apply) or write to us at customercare@tataaia.com. Visit us at: www.tataaia.com.• L&C/Misc/2021/Sep/0449.
RDAI is not involved in activities like selling insurance policies, announcing bonus or
BEWARE OF SPURIOUS/
FRAUD PHONE CALLS! investment of premiums. Public receiving such phone calls are requested to lodge a police
complaint.