A disability insurance questionnaire is the process which helps to assess the sum assured and insurance premium amount for the individual who wants to get insured for the amount lost in employment due to illness or bad health. The questions in this questionnaire should be appropriate so that the exact amount that the insure had lost can be traced along with the reason for it.

Sample Disability Insurance Questionnaire

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

Address: Street address __________ City name ________ State name _________

Postal code _________

Date of birth: ____________

Gender: __________

Height: ___________ Weight: __________

Residential Contact number: _____________ Mobile number: ________

Email id: ___________

1. Are you in employment in a full time basis or a seasonal basis?

a) Full time basis

b) Seasonal basis

2. Did you ever lose your job due to layoff in the company?

a) Yes

b) No

3. Do you have any history of missing office due to any health related problem?

a) Yes

b) No

4. If the answer to the above question is yes, what was the health related problem that you were suffering from and what is the amount of payment that you lost?


5. Have you received any pension or compensation for disability benefits?

a) Yes

b) No

6. Are you associated with any group disability insurance and if yes what is the sum assured?


7. Do you have any other individual disability insurance?

a) Yes

b) No

8. Please mention in brief about your medical history in last five years.