Car Insurance Questionnaire


A car insurance questionnaire should be filled by a person who wish to take car insurance. The questionnaire should ask details on the limits of coverage, details of cars owned, etc.

Sample Car Insurance Questionnaire:

First Name: _______________________ Last Name: _____________

Full Address: ____________________________________________

Phone Number: ________________________

Email address: _________________________

Q1. Please mention the limits of the car insurance for each of the following coverage:

Collision insurance limit: ____________

Rental Car coverage per day: _____________

Q2: Please specify if any drivers are to be covered in this insurance policy

Name of the driver: ____________ DOB: __________ State: ____ Driving license: ________ vehicle (s) driven: ______________

Name of the driver: ____________ DOB: __________ State: ____ Driving license: ________ vehicle (s) driven: ______________

Name of the driver: ____________ DOB: __________ State: ____ Driving license: ________ vehicle (s) driven: ______________

Q3: Mention the details of the car owned

Car name and model: _______________ Date of buy: _____________ Cost: ________________

Car name and model: _______________ Date of buy: _____________ Cost: ________________

Car name and model: _______________ Date of buy: _____________ Cost: ________________

Q4. Do you have any cars that are leased or taken on loan?

a)   Yes

b)   No

Q5: If the answer to the above question is ‘yes’, please provide the details of the lesser or lender

Name: _____________ Address: _________________________ Account number: ___________

Name: _____________ Address: _________________________ Account number: ___________

Name: _____________ Address: _________________________ Account number: ___________

Q6. Do you undertake periodic car maintenance?

a)   Yes

b)   No

Q7. If ‘yes’, please provide the frequency of the maintenance?

a)   Monthly

b)   Fortnightly

c)   Quarterly

d)   Yearly

e)   Rarely

Category: Insurance Questionnaire

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