ICC20-COVID-19 Questionnaire (8/2020)
COVID-19 QUESTIONNAIRE
P.O. Box 57220 | Salt Lake City, UT 84157-0220
Phone (801) 264-1060 | Toll Free (800) 574-7117 | Fax (866) 422-0009
COVID-19 Questionnaire Rules:
1. Questionnaire is only required on full benefit or first day coverage applications.
2. No questionnaire is required on full benefit applications under the age of 65.
3. If either question on the questionnaire is answered “yes” then we postpone the application for 25 days.
Name of Proposed Insured (please print):
Name of Owner (please print):
Application Date:
If the answer to any of these questions is “Yes”, submission of the insurance application will be postponed
for 25 days and subjected to further review.
Yes No
1. Within the past 30 days has the proposed insured been examined, diagnosed,
treated, been given medical advice, tested positive, or tested without results
regarding COVID-19 by a member of the medical profession?
2. Within the past 30 days has the proposed insured been quarantined or self-
isolated based upon the advice of a member of the medical profession regarding
Covid-19?
To the best of my knowledge, the answers to the above questions are true and complete. Any person who
knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject
to penalties under state law.
Proposed Insured’s Signature Date
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