A life insurance replacement questionnaire is needed to find the existing policies that are being taken by an insurance policy holder and to find the reasons why he or she is opting for a new life insurance contract. These types of questionnaires help the insurance companies to know the reasons as to why a customer replaces their life insurance policies.

Sample Life Insurance Replacement Questionnaire:

First Name of the Applicant: _______________________________

Last Name of the Applicant: _______________________________

Full Address: _______________________________________________________________

Phone Number: ____________________________

Email address: _____________________________

Age: _____________ Gender: ________

Q1. Will the new life insurance policy replace an existing life insurance contract?

a)   Yes

b)   No

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

Policy number: ____________________     Policy name: __________

Q3. Did the agent or registered representative present the relevant sales material?

a)   Yes

b)   No

Q4. What kind of insurance is the new investment policy?

a)   Level premium

b)   Increasing annual premium

Q5: What is your expected insurance coverage for death benefit?


Q6. Mention the purpose of adopting for a new insurance policy?


Q7. Mention the source of funds for the new insurance policy?

a)   Current earned income

b)   Net worth

c)   Amount of liquid assets

d)   Others, please mention ________________________________

Q8. How important is the cost of the new insurance policy on a scale of 1 to 5 where 1 is most important and 5 is least important?

a)   1

b)   2

c)   3

d)   4

e)   5

I have examined my financial goals and objectives including my existing policies and I find the new insurance annuity contract necessary for fulfil my needs. I have read and understood all the clauses given in the new contract.

Signature: ________________________

Date: ____________________________