Health Insurance Questionnaire


For a person to gain access to health insurance, it is necessary to fill in a health insurance questionnaire. A medical exam will also be required to back up any health related claims that are made. The information provided in the health insurance questionnaire makes it possible to evaluate an individual’s overall health and determines the kind of health insurance coverage that one will receive. The answers also influence the type of premiums that will be charged, depending on the person’s state of health. Private companies that provide health insurance services require a fully completed questionnaire before they can proceed to give the person health insurance cover.

Sample Health Insurance Questionnaire

Please complete the following questionnaire.

Please provide the information in full without the use of abbreviations.

What are the contact details of your health insurance provider?

Name………………………………….

Telephone number…………………………….

Fax number…………………………………….

E-mail address…………………………………

Address………………………………

City……………………………….Zip………………………………….

Do you need to receive medical care from a particular provider or medical practitioner?

……………………………………………………………..

Where are your claims sent to?

Name………………………………………………………….

Address…………………………………………………………

City…………………………………………Zip……………………………………….

What is the contact information of the individual to whom an insurance policy is to be issued?

Name (in full)…………………………….

Social security number…………………………….

Physical address………………………………..

Phone number…………………..

What is your insurance cover?  …………………………………………………………………..

What is the duration of your insurance cover?  …………………………………………………

Provide the following details of your employer, school or institution

Name………………………………………………………. Telephone Number……………………………

Address…………………………………………………….

City………………………….Zip………………………..

Does the beneficiary suffer from any known chronic illness that requires medical attention?

a.Yes

b.No

If you answer yes to the above question, please provide details of the condition…………………………………

Does the health insurance company offer cover for the following (please tick)?

a.Outpatient care

b.Inpatient care

c. Prescribed medication

d.Dental appliances

e.Home based care

Category: Health Questionnaire

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