Applicant Information: ID# 837223
Name: XXXX XXXXXXXX   Gender: XXXXXXXX   Birth date: 12/14/48 
Address: XXXXX XXXXXXXXXX XXXX   City: Orchard Park    State: New York    Zip: XXXXX
Work Phone: XXX-XXX-XXXX   Home Phone: XXX-XXX-XXXX    Best Time To Call: 8-20 a.m.
E-mail Address: 
Quote Information: Employment Information:
Are you requesting for yourself? Yes Occupation: Self employed
If no, who is request for? Me  
Health Information: Policy Information:

Do you use Tobacco: No

Your current insurance company: Golden Rule

What type of tobacco products: N/A

What type of plan do you currently have? HMO

Height: 6' 3"

How much are you paying per month? $689.00

Weight: 201

How many dependents do you have? 3

Health Problems: Blood Pressure

How old are those dependents? 13, 9, 6

Medications: None

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