Auto Accident Insurance Questionnaire


An auto accident insurance questionnaire is relevant for those who are either looking to take an auto accident insurance policy or are claiming for the reimbursements incurred in auto accident while being under an insurance policy. The following sample auto accident insurance questionnaire can help understand the type of questions to be framed.

Sample Auto Accident Insurance Questionnaire:

First Name: _______________________ Last Name: ____________

Full Address

Street: ______________City: _________________State: _________

Phone Number: ________________________

Email address: _________________________

Q1. Mention the details of the auto owned

Auto name and model: _______________ Date of buy: _____________ Cost: ___________

Auto name and model: _______________ Date of buy: _____________ Cost: ____________

Auto name and model: _______________ Date of buy: _____________ Cost: _____________

Q2. Did any of your autos met with an accident?

a)   Yes

b)   No

Q3. Please mention the date of the accident

____ / ______ / ______

Q4: Have you taken auto insurance?

a)   Yes

b)   No

Q5: Did you inform the auto insurer about the occurrence of accident?

a)   Yes

b)   No

Q6. Did you check with any other health care provider for treatment of your auto injuries?

a)   Yes

b)   No

Q7. If the answer to the above question is ‘yes’, please provide the details of the health care provider and the treatments received from them

Name: _____________ Treatment: _________________________

Name: _____________ Treatment: _________________________

Name: _____________ Treatment: _________________________

Q8. Have you contacted any legal authority for the auto accident?

a)   Yes

b)   No

Q9. If ‘yes’, please provide the details of the lawyer

Name: __________________ Phone: _________________

Q10. Please provide a description of the auto accident in not more than 3 lines.

________________________________________________

Category: Insurance Questionnaire

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