Annexure-I

LIFE INSURANCE CORPORATION OF INDIA

Questions related to Corona virus

To be submitted by the PH on revival

Policy number:

Name of the policyholder:

Tick whichever B. For

is applicable Resident
A. For Indians
NRIs
and
FNIOs
1. a) Present country Whether you have visited
of residence: any foreign country after
b) Date of recent 01.01.2020. If yes
visit to India: a) Name of the
c) Whether country visited:
screened at b) Duration of your
airport. If yes, stay(Specify date
submit the copy to date)
of report c) Date of return to
India:
d) Whether
screened at
airport. If yes,
submit the copy
of report
2. a) Have you been tested for COVID-19. If yes, report of the same to be
submitted
b) Have you been kept in quarantine since 01.01.2020 till date?
c) Have you been kept under observation?
d) Have you been kept in home/self isolation?
3. Have you any plan to visit any foreign country during the next 6 months.
If yes,
a) Name of the country/countries
b) Date of journey(to and fro) and duration of stay there

Date:

Place: Signature of the Policyholder/Proposer in case of minor LA