State Farm Life Insurance Questionnaire

A state farm life insurance questionnaire can be useful to be filled by clients who wish to apply for state farm life insurance policies that provide financial security to a family during any financial loss or death of a family member. Through this questionnaire, consumers can choose the right policies with a better coverage plan.

Sample State Farm Life Insurance Questionnaire:

First Name: _______________________ Last Name: _______________________________

Full Address: _______________________________________________________________

Phone Number: ________________________

Email address: _________________________

Age: _____________ Gender: ______

Date of Birth: ___/___/___ Height: _____ feet ___ inches

Weight: _____ lbs

Q1. Have you undergone blood, drug and urine tests?

a)   Yes

b)   No

Q2: Which of the following state farm life insurance policies do you want to opt for?

a)   Term Insurance

b)   Permanent Life Insurance

Q3: Which of the following is the preferred mode of payment for State farm life insurance premium?

a)   Online payment

b)   Mail payment

Q4. Please mention the state or province to receive the life insurance quotes and rates


Q5: Please mention the particular state farm life insurance policy that you want to subscribe for (if you are aware of the policy details)


Q6. Do you wish to take insurance dividends?

a)   Yes

b)   No

Q7. Please put down any specific comment about the policy that you want to opt for.


Q8: Do you possess a medical history of illness?

a)   Yes

b)   No

Q9. If ‘Yes’, please provide the details of your medical history

Illness or Disease: _________________ Treatment taken: _____________

Illness or Disease: _________________ Treatment taken: _____________

Category: Insurance Questionnaire

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