Due to the 2019-2020 outbreak of the novel Coronavirus (COVID-19), our business is taking extra precautions with the care of every client to include health history review and enhanced sanitation/disinfecting procedures in compliance with CDC guidance.
Symptoms of COVID-19 include:

• Fever
• Fatigue
• Dry Cough
• Difficulty Breathing

I agree to the following:

• I understand the above symptoms and affirm that I, as well as all household members, do not currently have, nor have experienced the symptoms listed above within the last 14 days.
• I affirm that I, as well as all household members, have not been diagnosed with COVID-19 within the past 30 days.
• I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 within the past 30 days.
• I affirm that I, as well as all household members, have not traveled outside of the country or to any city considered to be a “hot spot” for COVID-19 infections within the past 30-days.
• I understand that CAL-KOR Insurance Services cannot be held liable for any exposure to the COVID-19 virus caused by misinformation on this form or the health history provided by each client.

Our business is following theses enhanced procedures to prevent the spread of COVID-19:
[Body Temperature check, Universal use of face masks, Physical distancing and limiting contacts, Recommends washing hands with soap and water or hand sanitizer, Cleaning of frequently touched surfaces & High touch surfaces, Regular notice & training to prevent COVID-19]

By signing below, I agree to each statement above and release [CAL-KOR Insurance services] from any and all liability for unintentional exposure or harm due to COVID-19.