Coronavirus (COVID-19) Questionnaire

Complete what you know and submit. Anything you leave blank will not stop the submission, but the more detail you give an underwriter, the faster we can shop the case.

Download the printable PDF

Agent & Case Information

Agent Name(Required)

First Last

Phone(Required)

E-Mail(Required)

Proposed Insured

Client Name(Required)

First Last

You may enter client initials. We don't share client information with carriers on risk assessments.

Date of Birth(Required)

State(Required)

Height(Required)

Weight(Required)

Face Amount(Required)

Sex(Required)

Male

Female

Tobacco / Nicotine Use(Required)

Yes

Coverage Requested

Type of Insurance

Universal Life

Whole Life

Survivorship

Term

If term, number of years

Coronavirus (COVID-19) Questionnaire

Has the proposed insured ever been diagnosed with COVID-19 and/or had a positive test result?(Required)

Yes

What treatment was given?

What symptoms did the proposed insured have?

Fever

Cough

Shortness of breath or breathing difficulty

Fatigue or tiredness

Runny or watery discharge from the nose

Sore throat

Loss of taste and/or smell

Was the proposed insured hospitalized?

Yes

Duration of hospitalization

Was the proposed insured admitted to a hospital Intensive Care Unit?

Yes

Was the proposed insured put on a ventilator?

Yes

If yes, for how long?

Date of final discharge

Is the proposed insured fully recovered?

Yes

If yes, date of recovery

Does the proposed insured have any residuals?

Yes

If yes, please explain

Was this a single occurrence of COVID-19, or a re-occurrence?

Single

Re-occurrence

If re-occurrence, please list complete details

Has the proposed insured been vaccinated for COVID-19?

Yes

If yes, date of vaccination

Date of second shot if two were required.

Is the proposed insured currently taking any medication(s)?

Yes

If yes, provide name, dosage and frequency of medication(s)

Attachments

File Upload

Drop files here or

Max. file size: 512 MB.

Attach medical records, lab slips, pathology or test reports.

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Questions before you submit? Call the underwriting desk at 866.639.0443.