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Health Leads

This is a sample of Health Leads

Applicant Information: ID# 837223

Name: XXXX XXXXXXXX
Address: XXXXX XXXXXXXXXX XXXX
Work Phone: XXX-XXX-XXXX
E-mail Address: xxxxxxxx@earthlink.net
Gender: XXXXXXXX

Birth date: 12/14/48
City: Orchard Park
State: New York
Zip: XXXXX
Home Phone: XXX-XXX-XXXX
Best Time To Call: 8-20 a.m.

Quote Information:

Are you requesting for yourself? Yes

  • If no, who is request for? Me

Health Information:

Do you use Tobacco: No
What type of tobacco products: N/A
Height: 6′ 3″
Weight: 201
Health Problems: Blood Pressure
Medications: None

Employment Information

Occupation: Self employed

Policy Information:

Your current insurance company: Golden Rule
What type of plan do you currently have? HMO
How much are you paying per month? $689.00
How many dependents do you have? 3
How old are those dependents? 13, 9, 6