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LTC Leads

This is a sample of LTC Leads

Applicant Information: ID# 555743
Name: XXXX XXXXXXXX
Address: XXXXX XXXXXXXXXX XXXX
Work Phone: XXX-XXX-XXXX
E-mail Address: xxxxxx@earthlink.net

Gender: XXXXXXXX
Birth date: 12/14/48
City: Salt Lake City
State: Utah
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
Name of parent(s) (if not line 1): N/A
Are you married? Yes
In the past 5 years, have you been:

  • Confined to home: No
  • Rehabilitation: No
  • Previous Long Term Care: No
  • Home care: No

Health Information:

Do you use Tobacco: No
Height: 5′ 7″
Weight: 178
Health Problems: None
Describe: N/A
Are you diabetic? No
If diabetic, are you insulin dependent? N/A

Insurance Information:

Do you use one of the following:

  • Cane: No
  • Walker: No
  • Wheelchair: No

Other medical equipment, please describe: None
If you’ve required assistance with your everyday activities in the past 2 years please explain: None