Life Insurance Medical Questionnaire

The life insurance medical questionnaire has to be filled by an applicant who is applying for life insurance or health insurance. This type of questionnaire is intended to find information regarding the medical problems that an applicant has and throws light on health information of the applicant on the whole.

Sample Life Insurance Medical Questionnaire:

Name of the Applicant/Insured: _________________

Address: _____________________________ State: ________  Zip: _________

Phone Number: ______________

Email Address: ______________

Social Security #: ______________________________

Date of Last Medical/Health checkup:________  Dr: __________________

Q1.  Which of the following health harmful habits do you have?

  • Smoking
  • Alcohol abuse
  • Sleeping medication or drug abuse
  • Tobacco for chewing

Q2.  In the last 3 years, did you seek medical help for any of the following?

  • Cardiovascular
  • Liver or kidney
  • Blood or immune system
  • HIV
  • AIDS
  • Cancer
  • Respiratory
  • Nervous system
  • Musculoskeletal
  • Genitourinary

Q3.  Are you currently on any of the following categories of medicines?

  • Heparin
  • Anti-rejection drugs
  • Anti depressants
  • Insulin
  • Pain killers
  • Steroids

Q4.  Do you have any of the following medical conditions?

  • High blood pressure
  • Low blood pressure
  • Cholesterol
  • Diabetes
  • Arthritis
  • Epilepsy
  • Cataract

Q5.  Which of the following hazardous activities do you participate in?

  • Mountaineering
  • Rock climbing
  • Base jumping
  • Para gliding
  • Scuba diving
  • River rafting
  • Others

Q6. Which of the following life insurance plans do you require?

  • Term insurance
  • Permanent life insurance
  • Whole life insurance
  • Universal life
  • Limited-pay life insurance
  • Accidental death and dismemberment insurance
  • Endowments

Q7. What is the amount of premium are you looking at?

  • Less than $100
  • $100 – $300
  • $300 – $500
  • More than $500

Q8. What amount of death benefit or face amount do you require?


Q6. Have you ever been refused any insurance? If no, then state reasons

  • Yes
  • No
  • Reason:_____________

Category: Insurance Questionnaire

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