Coronavirus (COVID-19) Illness Reporting Form

Please complete this webform if you have recently been diagnosed with, exposed to, or in contact with someone who has been exposed to COVID-19. All responses will remain confidential and will only be visible to Human Resources. If you have been exposed or diagnosed, you are expected to refrain from coming into the office for a full 14 days or until you have been confirmed negative for the virus. During this time you may choose to work from home or utilize paid time off benefits. For questions please contact HR@marinerwealth.com

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COVID19-related Illness

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Experiencing cold or flu-like symptoms?*
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Sought medical care?*
Tested for COVID-19?*
Test results*

Reasonable Belief of Exposure

Have you, or a member of your household, been in contact with someone experiencing virus-like symptoms and may have been exposed to COVID-19?*

Please explain your relationship with the individual or situation that led to exposure.

Have they been diagnosed with COVID-19?*

Other Information

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