This is a sample of Disability Leads

Applicant Information: ID# 211643

Name: XXXX XXXXXXXX
Gender: XXXXXXXX
Birth date: 12/14/48
Address: XXXXX XXXXXXXXXX XXXX
City: Atlanta State: Georgia
Zip: XXXXX
Work Phone: XXX-XXX-XXXX
Home Phone: XXX-XXX-XXXX
Best Time To Call: 8-20 a.m.
E-mail Address: xxxxxx@earthlink.net

Employment Information:

Are you Self – Employed: Yes
If `No”, who is your employer: Scir Chiropractic
Your employer’s type of business: Chiropractic
What is your position: Doctor of Chiropractic
Years with your current employer: 3 – 6 Years
Occupation (BE SPECIFIC): Doctor of Chiropractic
Present Monthly Gross Income: $10,000.00
Monthly Benefit Requested: $7,500.00
Do you use Tobacco: No

Health Information:

What type of tobacco products: N/A
Height: 5′ 7″
Weight: 178
Participation in any hazardous activities: None
Waiting Period (injury to pay-out time): 30 Days
Benefit Period: 5 Years
Health Problems: None
Medications: None
Names/doses: N/A
Family member – Heart Disease/Cancer: None