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Below is personal information submitted for a quote. It was
submitted by
Jason Prospect jason.prospect@somewhere.com on Friday, January 14,
2008 at 20:12:03
and has been assigned tracking number "AZ51523".
Health Insurance Lead via 4freequotes.com's National Insurance Directory!
|
================Contact Information================= |
| Name: |
Jason Prospect |
| Home Address: |
123 Prospect Drive. |
| City, State, Zip: |
Sun city, AZ, 85373 |
| County: |
MARICOPA |
| Cellular: |
(555) 555-1212 |
| Email Address: |
jason.prospect@somewhere.com |
|
============== Applicant Info for Jason ============ |
| Gender: |
Male |
| Date of Birth: |
12/21/1961 |
| Height: |
5 Ft. 7 Inches |
| Weight: |
155 |
| Smoked in 12 Months: |
No |
| High Blood Pressure: |
No |
| Currently Employed: |
Yes |
| Self Employed: |
No |
| Occupation: |
Program Manager for 20 years or more |
|
=============== Medical History for Jason ========== |
| Medical Conditions: |
none |
| Ever Been Declined or Rated? |
No |
| Currently taking any Medication? |
No |
| Hospitalized in the last 5 years? |
No |
| Ever convicted of DUI/DWI? |
No |
| Immediate Relative had Heart Disease |
Yes |
| Immediate Relative Heart Disease Details: |
Father had heart attack |
| Immediate Relative had Cancer |
Yes |
| Immediate Relative Cancer Details: |
Father had cancer of the pancreas |
|
============== Applicant Info for Gina ============ |
| Gender: |
Female |
| Date of Birth: |
08/24/1957 |
| Height: |
5 Ft. 3 Inches |
| Weight: |
120 |
| Smoked in 12 Months: |
No |
| High Blood Pressure: |
No |
| Currently Employed: |
Yes |
| Self Employed: |
No |
| Occupation: |
Regional manager for 20 years or more |
|
===============Medical History for Gina ========== |
| Medical Conditions: |
none |
| Ever Been Declined or Rated? |
No |
| Currently taking any Medication? |
Yes |
| Details of current Medication: |
Evista, 60mg, 1 per day |
| Hospitalized in the last 5 years? |
No |
| Ever convicted of DUI/DWI? |
No |
| Immediate Relative had Heart Disease |
Yes |
| Immediate Relative Heart Disease Details: |
Father has had heart attack and bypass surgery |
| Immediate Relative had Cancer |
No |
|
=========================================== |
| In US less than 12 months?: |
No |
|
=========================================== |
|
============== Current Coverage Info ============ |
| Current Insurance status: |
I am currently under a group plan and am losing my
coverage |
| Current Company: |
Great West |
| Policy Renewal Date: |
3/1/2008 |
| Current Premuim: |
$700 |
| Current Premuim Billing Period: |
Monthly |
|
============== Required Coverage ============ |
| Dependent Coverage: |
Spouse Only |
| Maternity Coverage: |
No |
| Types of plans interested in: |
Preferred Provider Organization PPO |
|
====================================================== |
|
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