 |
| For: |
Agent's Name |
| Lead ID: |
70493 |
| Insurance Type: |
LTC |
| Date: |
07/28/2002 |
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| Contact Information |
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| Need Quote: |
ASAP |
Best Day: |
Anyday |
| |
|
Best Time: |
Anytime |
| Name: |
John Doe |
Day Phone: |
(850) 256-1276 x 23 |
| Address: |
4536 Alaska ave |
Evening Phone: |
(850) 722-0310 |
| City: |
Kalskag |
Cell Phone: |
(878) 310-2386 |
| County: |
Bethel |
Fax: |
(850) 722-0310 |
| State: |
AK |
Email: |
johndow@email.com |
| Zip Code: |
99607 |
Alternate Email: |
johndow@altemail.com |
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|
| Personal Information - Melody Lacy |
| Name: |
John Doe |
Self |
Height: |
6 feet, 5 inches |
| DOB: |
3/5/1961 |
Age: |
43 |
Weight: |
200 pounds |
| Gender: |
Male |
Marital: |
Single |
US/CA Residence: |
Yes |
| Education: |
Other |
Tobacco Usage: |
No |
| Occupation: |
Employed |
Alcohol Consumption: |
No |
|
| Currently Insured: |
No |
Ever Denied LTC: |
No |
| Work/Volunteer: |
No |
Retirement Community: |
No |
| State Medical, SS Disability or Workmen's Compensation: |
Yes |
| Comments: |
| I Am Disabled And Receive Medicare And Medical. I Work In An Internship As A Grant Writer Which I Hope Will Become A Comercial Enterprise In The Future. |
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|
| Medical Treatments: |
Yes |
Day/Home Care: |
No |
| Moving Help: |
No |
Driving Needs: |
Yes |
| Medical Equipment: |
Yes |
Pending Surgery: |
No |
| Comments: |
| I Receive Continuing Care From My General Practitioner And My Psychiatrist. I Use A Cane When Walking. |
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| Diagnoses: |
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| Comments: Please, contact me ASAP! |
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