Life Insurance Fact Finder
This takes about 5 to 7 minutes. The more complete your answers, the more accurate your quote will be, and the fewer follow-up questions we'll need to ask. Your information is kept private and is only used to shop coverage for you.
About You
Legal first name *
Legal last name *
Date of birth *
Sex *As listed on your ID. Carriers price by this.
Male
Female
State you live in *
South Carolina
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
ZIP code
Phone *
Email *
Best way to reach you *
Phone call
Text
Best time to reach you
Select one
Morning
Midday
Afternoon
Evening
Anytime
How did you hear about us?
Select one
Google search
Existing client
Friend or family referral
Event or community group
Other
Who referred you, or where did you hear about us?
The Coverage You Want
What do you want this policy to do? *Check all that apply.
Replace my income for my family
Pay off the mortgage
Cover funeral and final expenses
Pay for my kids' college
Leave an inheritance
Business need (key person, buy-sell, or loan requirement)
Something else
Coverage amount you have in mind *
Select one
Under $50,000
$50,000 to $100,000
$100,000 to $250,000
$250,000 to $500,000
$500,000 to $1,000,000
Over $1,000,000
Not sure, help me figure it out
Specific amount (if you know it)
Type of policy *
Term (covers a set number of years)
Permanent (whole life or universal life)
Not sure, show me both
How many years of coverage?
Select one
10 years
15 years
20 years
25 years
30 years
Not sure
Monthly budget for the new policy
Who would be the beneficiary?
Household and Finances
Carriers use income and debts to confirm the amount of coverage makes sense for your situation.
Occupation / job title *
Annual gross income *
Marital status *
Select one
Single
Married
Domestic partner
Divorced
Widowed
Would your spouse or partner like a quote too?
Yes
No
Maybe
Do you have children? *
Yes
No
Their ages
Mortgage balance (if any)
Other debtsCar loans, student loans, credit cards, etc.
Health
These answers decide your rate class. Being upfront now means no surprises later.
Height (ft) *
Height (in) *
Weight (lbs) *
In the past 5 years, have you used any tobacco or nicotine? *Includes cigarettes, cigars, vaping, chew or dip, nicotine pouches, gum, and patches.
Yes
No
Which types?
Cigarettes
Cigars
Vape / e-cig
Chew / dip
Pouches (Zyn, etc.)
Gum / patch
How often?
Date of last use
Do you use marijuana in any form? *
Yes
No
How often, and in what form?
Have you ever been diagnosed with or treated for any of these? *Check all that apply.
None of these
High blood pressure
High cholesterol
Diabetes or prediabetes
Heart disease or heart attack
Stroke or TIA
Cancer
Sleep apnea
Asthma, COPD, or other lung
Anxiety, depression, or other mental health
Kidney or liver condition
Alcohol or drug treatment
Other
Tell us about anything you checkedWhen diagnosed, how it's treated, and how well it's controlled. For cancer, include the type and date treatment ended.
In the past 10 years, have you been hospitalized or had surgery? *
Yes
No
What for, and when?
Are you waiting on any tests, results, or a referral to a specialist? *
Yes
No
What are they for?
Current prescription medicationsLeave blank if none. The reason matters as much as the drug.
+ Add another medicationHas a parent or sibling been diagnosed with or died from heart disease, stroke, or cancer before age 60? *
Yes
No
Not sure
Who, what condition, and at what age?
Driving and Lifestyle
In the past 5 years, any DUI/DWI, reckless driving, license suspension, or more than 2 speeding tickets? *
Yes
No
What happened, and when?
Have you ever been convicted of a felony, or do you have any charges pending? *
Yes
No
Brief description and date
Have you filed for bankruptcy in the past 5 years? *
Yes
No
Do you do any of these?Check all that apply.
Fly as a private pilot
Scuba diving
Rock or mountain climbing
Skydiving or hang gliding
Motor racing
Do you plan to travel outside the U.S. in the next 12 months? *
Yes
No
Where, and for how long?
Current Coverage
Do you currently have life insurance? *Include coverage through work.
Yes
No
Insurance company
Coverage amount
Type
Select one
Term
Whole life
Universal life
Group / through my employer
Not sure
Monthly premium
If term, what year does it end?
Plan for your current policy
Keep it and add more
Replace it
Not sure
Have you ever been declined, postponed, or charged extra for life insurance? *
Yes
No
Which company, when, and the reason (if you know it)
Do you have an application pending with another company right now? *
Yes
No
Anything Else
Questions, concerns, or anything else we should know
I understand this is not an application for insurance and no coverage is in effect until a policy is approved and issued by an insurance company. I agree that Mauldin Insurance Group may contact me by phone, text, or email about my request. *
Send My Information
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