Life Insurance Health Questionnaire


A life insurance health questionnaire is a well drafted document that has been designed to assess the health history of an individual applying for health insurance in a life insurance company. The questionnaire helps the life insurance company to know whether the client can be granted life insurance or not and also to ascertain the risks involved by giving him the policy and amount to be paid as premium. This questionnaire is provided to the individual when he approaches the insurance company for a health insurance policy and it is in the form of a form that the customer needs to fill up.

Sample Life insurance health questionnaire:

 

Name: _______________________

Address: _____________________

Mobile number: _____________

Residential Phone Number: _______________

Working Phone Number: ________________

Email id: _____________________________

Q1. Do you suffer from any regular health problems?

a)   Yes

b)   No

Q2. If the answer to the above question is yes, please describe the health problem in detail and how regularly do you suffer from it?

_____________________________

Q3. Have you been hospitalized in the last five years?

a)   Yes

b)   No

Q4. If yes, what was the reason for hospitalization and how many times were you hospitalized?

______________________

Q5. How regularly do you smoke?

a)   Everyday

b)   Often

c)   Sometimes

d)   Rarely

e)   Never

Q6. How often do you consume alcohol?

a)   Everyday

b)   Often

c)   Sometimes

d)   Rarely

e)   Never

Q7. Do you have any kind of disability and if yes what kind of disability?

___________________________

Q8. Have you ever taken any of the following in the past?

a)   Narcotics

b)   Steroids

c)   Other chemical substance

Category: Insurance Questionnaire

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