Health Insurance Lead Sample

Below is a sample containing the data fields that we attempt to capture and any leads you purchase at will always be in same column arrangement which is similar to or exactly the below. Each of our vendor's forms have different fields and info each consumer opts to fill in varies but you will always receive at least the required fields below indicated by an asterisk. The leads will be retrievable upon purchase in the orders area in a .csv format that will open right up into an Excel Spreadsheet if you have Excel on your computer. You should be able to print 30-50 leads per excel spreadsheet page depending on font size you select.

Contact Information
Date/Time*: 1/1/2012 12:20
Applicant Name*: John Doe
Street Address*: 1234 Main St.
City*: Los Angeles
Zip Code*: 90016
Phone Number*: (310) 555-1212
Best Time to Call*: Evening
Email Address*:
IP Address:
Policy Information
Currently Insured: Yes
Current Carrier: Aetna
Length with Company: 3 Years
Coverage For: Family
Denied Insurance: No
Desired Deductible: $1,000
Desired Coinsurance: $20
Desired Plan Type: PPO
Employed: Yes
Marital Status: Married
Medical Information
Date of Birth*: 1/1/1970
Gender: Male
Height: 6 Feet 1 Inches
Weight: 180 Pounds
BMI: 24.7
Pre-existing Conditions: No
Smoker: No
Drinker: No
Hospitalized Before: No
DUI or DWI Before: No
Current Medications: Blood pressure
Past Medications: None
Comments: In good health
Spouse Medical Information
Spouse Name: Jane Doe
Spouse Date of Birth: 1/1/1970
Spouse Height: 5 Feet 7 Inches
Spouse Weight: 150 Pounds
Spouse Smoker: No
Children Medical Information
Child 1 Name: Jack Doe
Child 1 Date of Birth: 1/1/2000
Child 1 Height: 4 Feet 4 Inches
Child 1 Weight: 75 Pounds
Child 1 Smoker: No
Child 2 Name: N/A
Child 2 Date of Birth: N/A
Child 2 Height: N/A
Child 2 Weight: N/A
Child 2 Smoker: N/A
Child 3 Name: N/A
Child 3 Date of Birth: N/A
Child 3 Height: N/A
Child 3 Weight: N/A
Child 3 Smoker: N/A