Sample Insurance Questionnaire

A sample insurance questionnaire is very important to get personal details of the individual who is planning to get an insurance done. This questionnaire is also used to get details of the object or property which the owner is planning to get insured. This questionnaire is used by insurance companies to decide the insurance premium that needs to be paid and the sum assured that the individual should get.

Sample Insurance Questionnaire

Name: First name: _______ Middle name: __________ Surname: _________

Address: Street address __________ City name ________ State name _________

Postal code _________

Date of birth: ____________

Gender: __________

Residential Contact number: _____________ Mobile number: ________

Email id: ___________

1. Do you have any kind of insurance?

a) Yes

b) No

2. If the answer to the above question is yes, what kind of insurance are you covered with?


3. Does anyone else in your family have any kind of insurance?


4. Does your employer cover you with any kind of insurance?

a) Yes

b) No

5. Have you ever been hospitalized in the last three years?

a) Yes

b) No

6. If the answer to the above question is yes, what was the reason for you to get hospitalized and what was the total expense that you had to incur for your hospitalization?

7. Are you addicted to any of the following?

a) Alcohol

b) Cigarettes

c) Tobacco

d) Narcotics

e) Steroid

8. Is there any history of genetic illness in your family?

a) Yes

b) No

9. If yes, do you have that same illness?


Category: Insurance Questionnaire

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