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    Covid Questionnaire

    Uploaded by

    Ashher Usmani
    This document is a COVID-19 questionnaire from HDFC Life Insurance Company for an insurance application. It asks the applicant, Mr. Ajay Kumar, questions regarding their travel history, COVID-19 testing and symptoms, occupation, and vaccination status. The applicant answers "no" to all questions. The document includes a declaration stating that the information provided is true and complete.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Covid Questionnaire

    Uploaded by

    Ashher Usmani
    298 views1 page
    This document is a COVID-19 questionnaire from HDFC Life Insurance Company for an insurance application. It asks the applicant, Mr. Ajay Kumar, questions regarding their travel history, COVID-19 testing and symptoms, occupation, and vaccination status. The applicant answers "no" to all questions. The document includes a declaration stating that the information provided is true and complete.

    Original Title

    1100079170046_Covid_Questionnaire

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    This document is a COVID-19 questionnaire from HDFC Life Insurance Company for an insurance application. It asks the applicant, Mr. Ajay Kumar, questions regarding their travel history, COVID-19 testing and symptoms, occupation, and vaccination status. The applicant answers "no" to all questions. The document includes a declaration stating that the information provided is true and complete.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    298 views1 page

    Covid Questionnaire

    Uploaded by

    Ashher Usmani
    This document is a COVID-19 questionnaire from HDFC Life Insurance Company for an insurance application. It asks the applicant, Mr. Ajay Kumar, questions regarding their travel history, COVID-19 testing and symptoms, occupation, and vaccination status. The applicant answers "no" to all questions. The document includes a declaration stating that the information provided is true and complete.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    COVID-19 Questionnaire

    Thank you for applying for a policy from HDFC Life Insurance Company Limited. To enable us to assess your application,
    please send this questionnaire duly answered, endorsed and verified by the "Life to be Assured"/Prospect and Proposed Policy Holder, if any.

    Application No. 1100079170046

    Name of Life to be Assured Mr. AJAY KUMAR

    Name of Proposed Policyholder (if different from Life to be Assured)

    1. Have you travelled outside India or your country of residence in the last 15 days or do you
    YES / NO-No
    plan to during the next 3 months?

    2. Have you been tested positive for COVID-19* or are awaiting results of such a test or been
    YES / NO - No
    advised to be under quarantine due to COVID-19*?

    3. Are you currently suffering from or in the last 1 month, have suffered from fever, persistent
    cough, sore throat, breathing difficulties, gastro-intestinal symptoms (vomiting/ diarrhoea) or YES / NO-No
    been in in contact with an individual suspected or confirmed to have COVID-19 *?

    4. Are you a Healthcare professional or enrolled as a Corona virus Warrior in a hospital/ clinic
    with COVID-19 facility and/ or treating/ in contact with COVID-19 infected individuals or YES / NO-No
    contaminated material?

    5. Have you been vaccinated for COVID-19*? YES / NO - No


    * Novel Coronavirus, SARSCoV-2/COVID-19
    An incomplete questionnaire will not be considered valid.
    Declaration :

    Where Proposed Policyholder and Life To Be Assured is the same person:

    I Mr. AJAY KUMAR ,(Name EDITABLE) s/o, d/o, w/o ........................................... (NAME EDITABLE) confirm and declare that I am the Life to be Assured in the above mentioned Application
    Number. I solemnly declare that the information provided herein is true and complete in all respects. I understand that the aforementioned information provided by me shall form an integral
    part of the proposal made by me for an insurance policy with HDFC Life Insurance Co. Ltd. and I agree that failure to disclose any material fact or providing wrong information shall invalidate
    the contract/policy issued by HDFC Life Insurance Co. Ltd.

    Where Proposed Policyholder and Life To Be Assured is not the same person:

    I ,(Name EDITABLE) s/o, d/o, w/o ........................................... (NAME EDITABLE) ("Proposed Policyholder") solemnly declare that the information pertaining to Mr/ Ms ("Life To Be Assured")
    provided herein is true and complete in all respects. I understand that the aforementioned information pertaining to the Life To Be Assured shall form an integral part of the proposal made by
    me for an insurance policy from HDFC Life Insurance Co. Ltd. and I agree that failure to disclose any material fact or providing wrong information shall invalidate the contract/ policy issued by
    HDFC Life Insurance Co. Ltd.

    I ,(Name EDITABLE) s/o, d/o, w/o ..........................................., (NAME EDITABLE) the Proposed Policyholder in the aforementioned Application Number solemnly declare that I accept
    and confirm the Declaration made above. I hereby declare that due to nationwide lockdown in the wake of Covid 19 pandemic and its logistical constraints, I am unable to provide either a
    signed physical copy or a scanned copy of the signed Covid-19 Questionnaire ("Questionnaire"). Hence, please consider the duly filled Questionnaire sent through my email address
    registered with HDFC Life, deemed to be signed by me on the date the email is sent. I understand that the Questionnaire shared through my registered email ID shall be binding on me and is
    enforceable in the court of law. I shall be solely liable/responsible towards HDFC Life for placing its reliance on my email and the attached Questionnaire.

    HDFC Life Insurance Company Limited [Formerly HDFC Standard Life Insurance Company Limited] (HDFC Life).
    CIN: L65110MH2000PLC128245. IRDAI Registration No. 101.
    Regd. Off: 13th Floor, Lodha Excelus, Apollo Mills Compound, N.M. Joshi Marg, Mahalaxmi, Mumbai - 400 011.
    For queries or more information, Call 1860-267-9999 (local charges apply). DO NOT prefix any country code e.g. +91 or 00. Available Mon-Sat from 10 am to 7 pm |
    Email - [email protected] | [email protected] (For NRI customers only) Visit - www.hdfclife.com

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