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Here is an example Disability Lead.
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Below is personal information submitted for a quote. It was
submitted by
Felicia Prospect f.prospect@somewhere.com on Wednesday,
February 1, 2008 at 18:44:03
and has been assigned tracking number "MD1138837443FE".
Disability Insurance Lead via 4freequotes.com's National Insurance Directory!
|
========== Contact Information ========= |
| Name: |
Felicia Prospect |
| Home Address: |
3547 Prospect Dr |
| City, State, Zip: |
Delmar, MD, 21875 |
| County: |
Wicomico |
| Cellular: |
(555) 555-0000 |
| Email Address: |
f.prospect@somewhere.com |
|
=============== Applicant Info for Felicia ============= |
| Gender: |
Female |
| Date of Birth: |
7/1/1955 |
| Height: |
5 Ft. 5 Inches |
| Weight: |
134 |
| High Blood Pressure: |
No |
| Currently Employed: |
Yes |
| Self Employed: |
No |
| City, State or Federal employee: |
No |
| Occupation: |
Office RN |
| Please provide a brief description of your duties:
|
assessing patients, taking vital signs, giving
injections assisting the physician |
| How long have you had this occupation? |
20 years or more |
| Annual Income: |
$45,000 |
| Pregnant: |
No |
| Married: |
Yes |
|
============== Risk Factors ============= |
| Involved in High Risk Activities? |
No |
| Active Military or Reserve? |
No |
| Piloted, co-piloted or been a crew-member within the
last 3 years? |
No |
| Worked in any type of hazardous occupation in the last
two years? |
No |
| Been advised to reduce alcohol consumption? |
No |
| Tobacco Use: |
I have Never used tobacco products of any form |
| Received disability compensation? |
No |
| Drivers license suspended or revoked? |
No |
|
============== Medical History ============= |
| Medical Conditions: |
none |
| Ever Been Declined or Rated? |
No |
| Currently taking any Medication? |
Yes |
| Details of current Medication: |
Fosomax calcium Prempro |
| Hospitalized in the last 5 years? |
Yes |
| Details of Hospitalization: |
Fractured Rt olecranon Process and Fractured Rt
humerus 4/05 and 8/05
|
| Ever convicted of DUI/DWI? |
No |
| been advised by a physician to reduce alcohol
consumption?: |
No |
|
=========================================== |
| U.S. Citizen? |
Yes |
|
=========================================== |
|
=========== Current Disability Coverage Info ============ |
| Currently have Disability Insurance? |
No |
|
================= Desired Coverage =============== |
| Monthly Benefit: |
70% |
| Length of Benefits: |
2 Years |
| Benefits to begin: |
30 days after disability |
| Additional Coverage Comments: |
I am also looking for something for hospitalization
supplements |
|
================================================= |
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