Liability Insurance Questionnaire

A liability insurance questionnaire can be used to analyse the details of the liabilities that a company is currently under the present insurance plan. The intention of the questionnaire is to disclose all necessary and relevant information to the insurance advisor to submit the claim on the company’s behalf to the insurer.

Sample Liability Insurance Questionnaire:

Name of the company: _______________________

NAIC Number of the company: ________________

Full Address of the company: ________________________

City: ____________ State: __________ Zip Code: _________

Contact Number: ________________ Fax: _______________

Email address: __________________ Website: ______________

Policy number: _____________

Effective date of the Policy: _________________

Expiration date of the Policy: ________________

Q1: Mention the full names of the persons insured or companies insured under this policy?


Q2: Mention the year of establishment of this business


Q3: Are there any charges pending against the company?

a)   Yes

b)   No

Q4: Has the company ever been liquidated or declared bankrupt?

a)   Yes

b)   No

Q5: What is the gross turnover of the company?

$ __________________

Q6: What is the total number of employees currently working in the company?


Q7: Does your company import or export goods?

a)   Yes

b)   No

Q8: If the answer to the above question is ‘Yes’, please provide the details of the products being exported or imported?


Q9. Please provide the details of all the claims within the last 5 years for

Date of loss: ___________Claim details: _________________ Amount Paid: _________ Amount Unpaid: ________

Date of loss: ___________Claim details: _________________ Amount Paid: _________ Amount Unpaid: ________

Date of loss: ___________Claim details: _________________ Amount Paid: _________ Amount Unpaid: ________

Q10. Do you wish to disclose any more details regarding this insurance policy?


Category: Insurance Questionnaire

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