Example Health Insurance Lead

Lead Number: 5005634
Lead Type: Health Insurance
Date Received: 02/03/2005

Contact Infomation:
Name: Patty Remaldi
Address: 6340 Beech St.
City: Plano
State: TX
Zip: 75093
Primary Phone: (972) 267-2844
Alternate Phone: (972) 267-3003
Email: pattyremaldi@hotmail.com

Insured Information:
Sex Age Height Weight
----- ---------- ---------- ---------
Primary: Male 42 5'9" 160
Spouse: 42 5'6" 180
Child 1: M age: 8
Child 2: M age: 6
Child 3: M age: 2
Child 4: age:

Insureds that currently use tobacco: No
Applicants that are currently Insured: None
Self Employed: yes
Occupation: Business Owner

Policy Information:
If insured, carrier name:
Does employer offer a group policy: No
Full Time Student: No
Duration of Coverage needed: More than 6 months
Diabetes: No
Date Coverage needed: 3/1/2005

Health Conditions, Medications, and Other Information:
Is anyone to be covered currently pregnant? No
Other Health Conditions and Information: