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Lead Type: Health Insurance
Date Received: 01/06/2006

Contact Infomation:
Name: Greg Broward
Address: 5408 White Pine St.
City: Durham
State: NC
Zip: 27705
Primary Phone: (919) 383-9887 Day
Alternate Phone: (919) 502-6407 Day
Email: gbroward21@yahoo.com

Insured Information:
Sex dob Height Weight
----- ---------- ---------- ---------
Primary: Male 01/19/1981 6'1" 160
Spouse: Female 09/24/1982 5'7" 120
Child 1: Female 12/21/1998
Child 2: //
Child 3: //
Child 4: //

Insureds that currently use tobacco: None
Currently Insured: Yes
If insured, carrier name: Not Listed
Self Employed: No
Occupation:

Policy Information:
Full Time Student: Yes
Duration of Coverage needed: More than 6 months
Diabetes: No
Date Coverage needed: 02/04/2006

Health Conditions, Medications, and Other Information:

Is anyone to be covered currently pregnant? No

Other Health Conditions and Information: