COVID-19 (Coronavirus) Exposure Questionnaire

COVID-19 (fldfrdakd ffjri) ksrdjrK m%Yakdj,sh

Life to be Assured’s Full Name :

Ôú; rlaIKh ,nkakdf.a iïmQ¾K ku:………………………………………………...………………………………………………………………….…….
Proposal Number :
fhdackdm;% wxlh:………………………………………………………………………………………………...……………………………...…….…………
Date of Birth:
Wmka Èkh: ………………………………………………………………..………………………………………………………….………………...…...……

1. Have you ever tested positive for the novel coronavirus (SARS-CoV-2/COVID-19)? If yes, provide the date of positive
diagnosis. And details of subsequent tests./ floskl fyda Tn fldfrdakd ffjri (SARS- CoV2/COVID-19) wdidos;fhl= nj mrSlaIKhlska
;yjqrej we;ao? tfia kï ;yjqre lr.;a oskh iy iïmQ¾K úia;r imhkak.

A. If yes, then, ms<s;=r “Tõ” kï

Whether you were hospitalized? /frday,a .;j m%;sldr ,enqfõo?
Asymptomatic home quarantined? /frda. ,laIK j,ska f;drj ksjfia ksfrdaOdhkhj isáfhao?

B. If yes, then whether you suffered Covid-19 related Complications? If yes give details/ ms<s;=r “Tõ” kï fldfrdakd
ffjri wdY%s; ixl+,;d fmkakqï flrefkao? ms<s;=r “Tõ” kï úia;r imhkak.

2. Have you been vaccinated for COVID19? please provide copy of Covid-19 vaccination certificate or provide COVID-19
Vaccination details mentioned below?/ Tng fldfrdakd ffjri m%;sfrdaOl tkak; ,ndoS ;sfío? tu tkak; ,nd.;a nj ;yjqre flfrk
iy;slh fyda ta nj ikd;l, yels f,aLKhl msgm;la bosrsm;a lrkak. (mqoa.,sl m%ldY wkqu; lrkq fkd,efí).

A. Date of administration of the first dose? m,uq ud;%dj ,nd.;a oskh? ...............................................
B. Date of administration of the second dose? fojk ud;%dj ,nd.;a oskh? …….......................................
C. Date of administration of Booster dose? nQiag¾ ud;%dj ,nd.;a oskh? ...............................................

Copy of latest vaccination certificate is mandatory for all insurance application in following: /tkak; ,nd.;a nj ;yjqre flfrk
iy;slh fyda ta nj ikd;l, yels f,aLKhl msgm;la bosrsm;a lsrSu my; wjia:djkaysoS wksjd¾h fõ:

• Non-Residential Sri Lankan /wfkajdisl YS% ,dxlslhka i|yd.

• Sum Under Consideration above LKR 10,000,000.00/ iïmQ¾K wjodkï w.h re:10,000,000.00 jeä wjia:djloS.

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).
Ôú; rlaIs;hdf.a m%ldYh
by; wid we;s m%YaK j,g ud úiska imhk ,o ms<s;=re i;H nj m%ldY lrñ. ;jo fuu wdlD;s m;%h ud úiska HNB weIqjrkaia PLC fj; bÈßm;a l, fhdackd m;%fhau
fldgila nj;a, lsishï jákd f;dr;=rla jika lsÍfuka tu .súiqu wfydais jk nj;a, ud okakd nj m%ldY lrñ.

……………………………………. …………..………… ………….……….……

Signature of Life to be assured Place Date
Ôú; rlaIKh ,nkakdf.a w;aik ia:dkh Èkh

LNBMQ18 Version 03 Issued on 20/07/2022 1