Insurance Claim Questionnaire
Q1. How long have you been a customer with us (in months)?
Possible Answers: Numeric input
Q2. What is your age?
Possible Answers: Numeric input
Q3. Please provide your policy number.
Possible Answers: Text input
Q4. When was your insurance policy activated?
Possible Answers: Date input (DD/MM/YYYY)
Q5. Which state did you purchase your policy in?
Possible Answers: Dropdown (List of Indian States)
Q6. What is the combined single limit (CSL) for your policy?
Possible Answers: Dropdown or Numeric input
Q7. What is your policy's deductible amount?
Possible Answers: Numeric input
Q8. What is your annual insurance premium (in ₹)?
Possible Answers: Numeric input
Q9. Do you have an umbrella insurance policy? If yes, what is the umbrella limit?
Possible Answers: Numeric input or 'None'
Q10. What is your residential ZIP/postal code?
Possible Answers: Numeric input
Q11. What is your gender?
Possible Answers: 1. Male
2. Female
3. Other
4. Prefer not to say
Q12. What is your highest level of education?
Possible Answers: 1. High School
2. Bachelor's
3. Master's
4. Doctorate
5. Other
Q13. What is your current occupation?
Possible Answers: Text input
Q14. Please list your hobbies or leisure interests.
Possible Answers: Text input
Q15. What is your relationship status?
Possible Answers: 1. Single
2. Married
3. Divorced
4. Widowed
5. Other
Q16. Do you have any capital gains to declare (₹)?
Possible Answers: Numeric input
Q17. Do you have any capital losses to declare (₹)?
Possible Answers: Numeric input
Q18. On what date did the incident occur?
Possible Answers: Date input (DD/MM/YYYY)
Q19. What type of incident was it?
Possible Answers: 1. Theft
2. Collision
3. Natural Disaster
4. Other
Q20. What was the nature of the collision (if any)?
Possible Answers: 1. Front Collision
2. Rear Collision
3. Side Collision
4. No Collision
5. Other
Q21. How would you describe the severity of the incident?
Possible Answers: 1. Minor
2. Moderate
3. Major
4. Total Loss
Q22. Were any authorities contacted?
Possible Answers: 1. Police
2. Fire Department
3. Ambulance
4. None
Q23. In which state did the incident occur?
Possible Answers: Dropdown (List of Indian States)
Q24. In which city did the incident occur?
Possible Answers: Text input
Q25. What is the exact location/address of the incident?
Possible Answers: Text input
Q26. At what hour did the incident occur? (0–23)
Possible Answers: Numeric input (0–23)
Q27. How many vehicles were involved in the incident?
Possible Answers: Numeric input
Q28. Was there any property damage?
Possible Answers: 1. Yes
2. No
3. Unknown
Q29. Were there any bodily injuries reported?
Possible Answers: Numeric input
Q30. Were there any witnesses present? If yes, how many?
Possible Answers: Numeric input
Q31. Was a police report filed?
Possible Answers: 1. Yes
2. No
Q32. What is the total claim amount you are filing (₹)?
Possible Answers: Numeric input
Q33. What is the amount being claimed for injury (₹)?
Possible Answers: Numeric input
Q34. What is the amount being claimed for property damage (₹)?
Possible Answers: 1. Yes
2. No
3. Unknown
Q35. What is the amount being claimed for vehicle repair/replacement (₹)?
Possible Answers: Numeric input
Q36. What is the make of your vehicle?
Possible Answers: Dropdown (e.g., Maruti, Hyundai, Honda, etc.)
Q37. What is the model of your vehicle?
Possible Answers: Text input
Q38. What is the manufacturing year of your vehicle?
Possible Answers: Numeric input (YYYY)
Q39. Do you confirm that this is a genuine claim and no fraud has occurred?
Possible Answers: 1. Yes, it is genuine
2. No, reporting fraud
