Term Life Insurance Questionnaire


A term life insurance questionnaire is a helpful document to understand the requirements of the client for a new term life insurance policy and suggest the best plan that is available with the agent or institution to the client.

Sample Term Life Insurance Questionnaire:

First Name: _______________________ Last Name: _______________________________

Full Address: _______________________________________________________________

Phone Number: ________________________

Email address: _________________________

Age: _____________ Gender: ______

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

Weight: _____ lbs

Q1. Are you currently under any life insurance policy?

a)   Yes

b)   No

Q2: If the answer to the above question is ‘yes’, mention the name of the policy that you are currently under?

________________________________________

Q3: Please provide the details of the life insurance policy that you are currently using

Term: _____ Maturity year: ____ Premium: _____ Insurance coverage amount: _________

Term: _____ Maturity year: ____ Premium: _____ Insurance coverage amount: _________

Q4. Why are you looking for a term life insurance policy?

______________________________________________

Q5: What is the amount of coverage that you are looking for with the new term life insurance policy?

________________________________________________

Q6. What is your preferred periodicity of paying premium?

a)   Annual

b)   Semi-annual

c)   Quarterly

d)   Monthly

Q7. What is your preferred mode of making premium payment?

a)   By Cash

b)   By linking with bank account and deducting it

c)   Others, please mention _________________________

Q8: Are you currently undergoing any medical treatment?

a)   Yes

b)   No

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

Blood Group: ________ Illness or Disease: _________________ Treatment: _____________

Blood Group: ________ Illness or Disease: _________________ Treatment: _____________

Q9. Do you consume nicotine or tobacco?

a)   Yes

b)   No

Category: Insurance Questionnaire

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