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For: Tom Agent
Type: Life |
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Contact Information |
Name: |
Jim Customer |
Email: |
jim@emailforyou.com |
Address: |
165 Long Street |
Daytime Phone: |
615-429-8645 |
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Anywhere, TN 37067 |
Evening Phone: |
615-865-4523 |
Time to Contact: |
Afternoons |
Fax: |
615-436-4785 |
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Coverage Information |
Currently Insured? |
No |
Current Company: |
N/A |
Type of Policy Wanted: |
Term 20 Year Guaranteed Level Premium |
Amount: |
$500,000 |
Coverage for Spouse? |
No |
Coverage for Children? |
No |
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Health Information |
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Male |
Occupation: |
High School Teacher |
Smoker? |
No |
Date of Birth: |
June 15, 1971 |
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6' 1" |
Weight: |
191 lbs. |
Rated/Declined last 5 yrs? |
No |
Hospitalzed last 5 years? |
No |
DUI/DWI last 5 years? |
No |
Resident of US/Canada for 5 years? |
Yes |
Currently takes prescription meds? |
No |
Medications / Dosages |
N/A |
Major Medical Conditions: |
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Addtional Comments: |
Was diagnosed with high blood pressure 7 years ago, but it has been under control for the last 4 years. Thanks. |
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