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For: Tom Agent
Type: Health |
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Contact Information |
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Name: |
Jim Customer |
Email: |
jimc@emailforyou.com |
Address: |
123 Sample Lane |
Daytime Ph: |
(123) 234-0934 |
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Anywhere, AL 90012 |
Evening Ph: |
(123) 234-4523 |
Best Time to Contact : |
Afternoon |
Fax: |
(123) 487-1274 |
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Coverage Information |
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Currently Insured?: |
Yes |
Company: |
Blue Cross / Blue Shield |
Currently Paying for COBRA?: |
No |
Current Plan: |
PPO |
Desired Plan Type: |
PPO |
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Deductible: |
$500 |
Office Copay: |
$25 |
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Health Information |
Applicant One |
Gender: |
Male |
Weight: |
197 lbs. |
Height: |
6' 1" |
Date of Birth: |
08/12/66 |
Occupation: |
Cleaning Business Owner |
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Applicant Two |
Gender: |
Female |
Weight: |
119 lbs. |
Height: |
5'5" |
Date of Birth: |
04/22/67 |
Occupation: |
Stay at Home Mom |
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All Applicants |
| Any Applicant Rated/Declined last 5 yrs? |
No |
Hospitalized last 5 years? |
No |
Any Applicant a Smoker? |
No |
Any Applicant had DUI/DWI last 5 years? |
No |
All Applicants Resident of US/Canada for 12 Months? |
Yes |
Any Applicant in Need of Maternity Coverage?
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No |
Any Applicant an Expectant Mother or Father? |
No |
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Any Applicant Currently takes prescription meds? |
No |
Medications / Dosages:
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Major Medical Conditions for Any Applicant:
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None |
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Addtional Comments: |
If possible, call me at work from 2-4pm. |
