Life Insurance Questionnaire Sample
Sex: Male / Female
Date of birth:________________ [dd / mm / yyyy]
1. Are you married, single or divorced?
2. If you are married, is your spouse covered by any insurance? Please give the details.
3. Are you employed by any company, private or government organization?
4. Does your employer cover you health or any other insurance?
5. Do you suffer from any regular health problem?
6. If the answer to the above question is yes, then please mention the nature and severity of your health problem. Also mention the amount you are spending annually/monthly on treatment and medication.
7. Have you been hospitalized in the last 5 years. How many times?
If answer to the previous question is yes, then list down your hospitalization details and also mention what were the expenditures spent on treatment.
8. Do you use or have used in the past, any of the following? If yes have you ever received treatment for the same?
Please give details?
Sex: Male / Female
Date of birth:________________ [dd / mm / yyyy]
1. Are you married, single or divorced?
2. If you are married, is your spouse covered by any insurance? Please give the details.
3. Are you employed by any company, private or government organization?
4. Does your employer cover you health or any other insurance?
5. Do you suffer from any regular health problem?
6. If the answer to the above question is yes, then please mention the nature and severity of your health problem. Also mention the amount you are spending annually/monthly on treatment and medication.
7. Have you been hospitalized in the last 5 years. How many times?
If answer to the previous question is yes, then list down your hospitalization details and also mention what were the expenditures spent on treatment.
8. Do you use or have used in the past, any of the following? If yes have you ever received treatment for the same?
Please give details?
- Tobacco
- Alcohol
- Narcotics
- Steroids
- Other drugs or chemical substance
PLEASE REGISTER YOUR NAME, EMAIL ADDRESS & TEL BELOW.
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