Mandatory COVID-19 Screening

Full Name*

Email*

Please Indicate any of the following that may apply to you:

Fever

Cough

Chills

Headache

Difficulty Breathing

Sore Throat

Runny Nose
(Not related to seasonal allergies)

Congestion
(Not related to seasonal allergies)

Have had a confirmed case of COVID - 19

Have been in close contact with a person who is sick or has a confirmed case of COVID-19 in the past 14 days

Have been in close contact with a person in the past 14 days who is being tested for COVID-19 or has a suspected case of COVID-19

No Symptoms

By agreeing, you verify that this information is correct*

Yes No

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Cardinal Planning
Ottawa, Ontario
Business: 613-791-8735

Please confirm with your advisor which company you are dealing with for each of your products and services. Insurance products and services are offered through PB Fraser and Company Inc.

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