A medical insurance questionnaire is a written document which consists of a set of questions which are asked from a person who is claiming or applying for a medical insurance. These questions help the organisation to know whether or not the candidate is suitable for getting a medical insurance. These questions can be directly or indirectly related to the topic and can be either in the form of multiple choice questions or subjective ones.

Sample Medical Insurance Questionnaire:

Name of the respondent: _________________

Age of the respondent: ___________________

Date of birth of respondent: _________________

Gender: ________________

Contact number of respondent: _______________

Email address: _________________

Residential address: __________________ zip code: ___________

State: _____________ country: ____________________

Please answer the following questions:

Q1. Do you receive your medical care from a particular medical practitioner?

a)   Yes

b)   No

Q2. If yes, then name the person.


Q3. Do you suffer from any chronic diseases or illness which requires medical care or attention? /

a)   Yes

b)   No

Q4. If yes, then name the illness/illnesses.


Q5. What is your insurance cover?


Q6. What is the duration of your insurance cover?


Q7. Provide the details of your employer:

Name: ______________

Company name: _______________

Contact number: _________________

Address of office: _____________________

Q8. Tick the points from the following which you want your insurance to cover:

a)   Outpatient care

b)   Inpatient care

c)   Prescribed medication

d)   Dental appliances

e)   Home based care

f)    Other(please mention)

Q9. Give us a reason so as to why we should provide you the medical insurance?