Life Insurance Questionnaire Sample

When you apply for life insurance, the insurer needs a clear picture of your health, lifestyle, and financial situation. A welldesigned questionnaire gathers that information efficiently while keeping the applicant comfortable. Below is a comprehensive sample questionnaire broken down into sections, with explanations of why each question matters and tips for answering accurately.

1. Personal Information

This section establishes the applicants identity and contact details. Accurate data ensures proper underwriting and future communication.

Key Questions

• Full Name as it appears on legal documents.
• Date of Birth determines agerelated risk factors.
• Social Security Number (or national ID) used for background checks.
• Marital Status influences beneficiary options and premium discounts.
• Address and Phone Number for mailing policy documents and contact.

2. Employment and Income

Insurers assess your ability to pay premiums and the financial need for coverage.

Key Questions

• Current employer and occupation certain jobs carry higher risk.
• Annual income helps determine appropriate coverage amount.
• Employment status (fulltime, parttime, selfemployed, retired).
• Length of time at current job stability can affect rates.

3. Desired Coverage

Clarifying the type and amount of coverage avoids under or overinsuring.

Key Questions

• Coverage amount (e.g., $250,000, $500,000, $1,000,000).
• Policy term 10, 20, 30 years, or whole life.
• Beneficiary designation primary and contingent beneficiaries.
• Optional riders (e.g., accelerated death benefit, waiver of premium).

4. Health History

Health is the most critical underwriting factor. Answer honestly; misleading information can void the policy.

Medical Conditions

• Do you have any diagnosed chronic illnesses? (e.g., diabetes, hypertension, heart disease).
• Have you ever been hospitalized or undergone surgery? Provide dates and reasons.
• Any history of cancer? Specify type, diagnosis date, and current status.
• Do you have any mental health conditions? Include treatment details if applicable.

Medications and Treatments

• List all prescription medications you are currently taking.
• Do you use any overthecounter supplements regularly?
• Are you undergoing any ongoing medical treatments or therapies?

5. Lifestyle and Habits

Activities, substance use, and daily habits affect risk assessment.

Key Questions

• Tobacco use cigarettes, cigars, chewing tobacco, vape.
• Alcohol consumption frequency and typical amount.
• Recreational drug use illegal substances, frequency.
• Exercise routine type, frequency, intensity.
• Vehicle usage daily commuting miles, type of vehicle.
• Highrisk hobbies skydiving, scuba diving, race car driving, etc.

6. Family Medical History

Genetic predispositions influence longevity and disease risk.

• Do any firstdegree relatives (parents, siblings, children) have a history of heart disease, cancer, stroke, or diabetes? Include age at diagnosis.
• Any known hereditary conditions in the family?

7. Existing Policies and Past Insurance

Current and previous life insurance information helps the underwriter avoid duplicate coverage.

• Do you currently hold any life insurance policies? Provide carrier, face amount, and type.
• Have you ever applied for life insurance and been declined, or had a policy lapse? Explain circumstances.

8. Consent and Signature

Most questionnaires end with a statement authorizing the insurer to obtain medical records and a signature line.

• I certify that all information provided is true and complete to the best of my knowledge.
• Applicants signature and date.

Sample Layout (HTML Table)

By following this sample questionnaire, insurers can gather the essential data needed for accurate underwriting while providing applicants with a clear, organized format. Remember that honesty is the best policyaccurate answers lead to fair premiums and a valid contract.