Sample Lead: Health

Contact Information:
Name:	Mark Smith	Email:	marksmith@yahoo.com
Address:	2 Timber lane	Phone:	(585) 223-5000
City, State, Zip:	Fairport, NY, 14450	Alt. Phone:
Prior Insurance Information:
No Prior Insurance
Desired Coverage Information:
Plan Requested:	Individual Family	Requested Benefits:	Dental, Vision
Occupation:	Management Consulting	DUI / DWI:	No
Medical Information:
Major Conditions:	No	Hospitalized:	No
Has Prescriptions:	Yes	Medical Treatment:	No
Medical Conditions:	None
Description & Prescriptions:	High Blood Pressure
Applicant #1:
Relation:	Primary	Height:	6'
Gender:	Male	Weight:	185 Lbs.
Date of Birth:	12 / 4 / 1972	Tobacco Use:	No
Applicant #2:
Relation:	Spouse	Height:	5' 1"
Gender:	Female	Weight:	140 Lbs.
Date of Birth:	8 / 12 / 1973	Tobacco Use:	No