Maxwell Auto, Home, Life and Health Insurance

Life Insurance Quote (No Obligation)

1) What type of Life Insurance are you seeking:

Term
Whole Life
Universal
Variable Universal
Not Sure

2) Please indicate the coverage amount:

3) What is your gender?

M F

4) What is your date of birth:

MM	DD	YYYY
/	/

5) Please provide your height:

ft. in.

6) What is your weight?

lbs.

7) Please indicate your marital status:

8) What is the highest Level of education you completed:

9) What is your current employment status:

10) Please select the industry which best describes your
occupation:

11) How long have you been at your present job?

Years Months

To help us ensure that we find the most competitive quote for your insurance needs, we’ll need some information about your day-to-day lifestyle, your medical history and your current health status. Please continue by answering the following set of questions to the best of your knowledge

12) In the past five years, have you used any form of tobacco or a nicotine substitute?
13) If you have, what forms of tobacco did or do you use?	Smoke Cigarettes Smoke Cigars Smoke A Pipe Chew Tobacco Chew Nicotine Gum 'The Patch'
14) If you currently smoke cigarettes, how many packs do you smoke per day?
15) Do you drink alcoholic beverages on a regular basis?	No Yes
16) If so, how many per week/month?	Qty
17) Have you received a DUI Or DWI in the last five years?	Yes No
18) Have you been hospitalized in the last five years?	Yes No
19) Are you currently taking any prescription medications?	Yes No
20) Are you a U.S. citizen?	Yes No
21) Have you lived or traveled outside the United States anytime during the last three years?	Yes No>
22) In the future, do you plan to leave the United States for travel or change of residence?	Yes No
23) To your knowledge, is there a history in your family (grandparents, parents or siblings) of cardiovascular disease before the age of 60?	Yes No
24) During the last 2 years, have you worked in any type of hazardous, occupation? (for example underground mining, high-rise construction work or explosives handling)	Yes No
25) Are you an active member of the military or military reserve?
26) Have you flown on an aircraft as a pilot, co-pilot or crew-member, within the last 3 years?
27) Do you participate in any risky activities such as racing, scuba diving, sky diving, mountain climbing, para-sailing or ultra light flying?	Yes No
28) Have you suffered any health symptoms related to the conditions listed below? If so please check the box next to the specific condition(s) that you have been advised you had or have been treated for:

Central Nervous System	Skin, Bones or Muscles	Mental Health, Drug Abuse
Epilepsy Multiple Sclerosis Alzheimer's Disease Cancer	Rheumatoid Arthritis Melanoma Cancer	Alcoholism Drug Abuse Mental Illness Depression
Digestive System	Respiratory System	Circulatory System
Chronic Kidney Disease Liver Disease Kidney Stones Gastric/Peptic Ulcers Ulcerative Colitis or Ileitis Neurogenic Bladder Bowel Incontinence Diabetes Mellitus Cancer	Asthma Emphysema Chronic Bronchitis COPD Cancer	Coronary Artery Disease Vascular Disease High Blood Pressure Stroke Elevated Cholesterol Cancer HIV

29) What range best describes your approximate household income:
30) Do you own or rent your residence:
31) Time at current residence:
32) Please describe your credit history:
33) Best Time To Contact:
34) Additional Comments: Please provide any additional information you feel is pertinent to the insurance coverage you need.

General Information:

1.	*First Name:
2.	*Last Name:
3.	*Phone:
4.	*Email:
5.	Address:
6.	Address:
7.	City:
8.	*State:
9.	*Zip Code:
10.	County: