NBRF263503042008

Comp/Feb/Int/5027

COVID-19 Questionnaire

Thank you for applying for a policy from HDFC 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.

Application No.

Name of Life to be Assured

Name of Proposed Policyholder

(if different from Life to be Assured)

1. Have you traveled abroad since 01/01/2020?

YES / NO

If YES, mention name of the country/countries travelled to

_____________________________________________________
DD/MM/YYYY
Date of return: _____________

YES / NO
2. Do you intend to travel abroad within the next 6 months?
If YES, mention name of the country/ countries
_____________________________________________________
DD/MM/YYYY
Intended date of travel: ______________
Duration of stay: ___________________

3. Are you currently suffering from or have suffered from flu like symptoms,
YES / NO
fever, sore throat, runny nose, persistent cough, sore throat, shortness of
breath, breathing difficulties, malaise, gastro-intestinal symptoms such as If YES, mention details: __________________________________
nausea, vomiting, diarrhea, advised to undergo test or awaiting test results
for COVID-19* ? Exact diagnosis: ___________________
DD/MM/YYYY
Date of diagnosis: ______________

4. If you were ever tested positive for COVID-19* have you made a full
YES / NO
recovery to good health and received clearance from government
authorities? If YES, mention details: __________________________________
DD/MM/YYYY
Date of discharge: ______________

5. Were you ever a) quarantined abroad or in India and released by the govern-
ment authorities with clearance for symptoms and disease OR b) are you
currently serving their notice of quarantine OR c) advised to self-isolate due to
exposure or symptoms of COVID-19* OR d) orders issued by government
health authorities or airport authorities?
Note: Isolation solely due to lockdown orders issued by government or local
administration is to be answered as NO
YES / NO
If YES, mention details: __________________________________
DD/MM/YYYY
Date of quarantine/ isolation: ______________
Reason: ______________________________________________
_____________________________________________________

6. Have you had direct contact with someone who has been confirmed or is YES / NO
suspected to be COVID-19* positive?
If YES, mention details: __________________________________

Relationship with Life Assured: ___________________________

7. Have your family members traveled abroad since 01/01/2020?

YES / NO

If YES, mention name of the country/countries travelled to :

____________________________________________________
DD/MM/YYYY
Date of return: ______________

* Novel Coronavirus, SARSCoV-2/COVID-19

 8. Are any of your family members currently suffering from or in the last 2
YES / NO
months suffered from flu like symptoms, pneumonia, fever, sore throat, runny
nose, persistent cough, shortness of breath, breathing difficulties, advised to If YES, mention details: __________________________________
undergo test for or awaiting test results for COVID-19* and/ or ever tested
positive for the COVID-19*? Relationship with Life Assured: ____________________________

Exact diagnosis: _______________________________________

DD/MM/YYYY
Date of diagnosis: _____________

An incomplete questionnaire will not be considered valid.

Declaration of Life to be Assured:

I agree and understand that the information given herein is true and complete in all respects and will form an integral part of the proposal made by me
for an insurance policy from HDFC Life Insurance Co. Ltd. and that failure to disclose any material fact known to me may invalidate the contract.

SIGN HERE SIGN HERE

DD/MM/YYYY DD/MM/YYYY
Date: __________________ Date: __________________
Place: __________________ Place: __________________
Signature of Life to be Assured Signature of Proposed Policy Holder
if different from Life to be Assured)

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 – service@hdfclife.com
| nriservice@hdfclife.com (For NRI customers only) Visit – www.hdfclife.com