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

COVID-19 Screening Form

This material has been prepared to provide information on the products and services offered through your Manulife Securities Incorporated (MSI). Manulife Securities is a Trade Name used by the related companies MSI (an Investment dealer). Manulife Securities related companies are 100% owned by The Manufactures Life Insurance Company (MLI) which in turn is 100% owned by the Manulife Financial Corporation a publically traded company. Please confirm with your Advisor which company you are dealing with for each of your products and services. Details regarding all affiliated companies of MLI are provided in the Important Client Information Brochure which can be found on the Manulife Securities website www.manulifesecurities.ca (http://www.manulifesecurities.ca) . Stocks, bonds and mutual fund products and services are offered through MSI, Manulife Securities Incorporated is a Member of the Canadian Investor Protection Fund and a Member of the Investment Industry Regulatory Organization of Canada. Insurance products and services are offered through PB Fraser and Company Inc. and Manulife Securities Insurance Inc. Banking products and services are offered by referral arrangements through our related company Manulife Bank of Canada, additional disclosure information will be provided by your Advisor upon referral.

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