Long Term Care Sample

Long Term Care Leadid:  65321

General Information

Gender:  Male

Date of Birth:  08/17/1965

Tobacco Use:   Smoker

Do you take any prescription medications?:   Yes

Currently have Long Term Care insurance:  No

Marital Status:  Married

Spouse Information

Date of Birth:  11/16/1984

Currently have Long Term Care insurance:  No

Complete routine Health exam (last 2 years):  Yes

Tobacco Usage:  Non Smoker

Care for someone other then spouse

Full Name:  N/A

Date Of Birth:  N/A

Relationship to you?:  N/A

Customer Information

Full Name:   Tim ****

Spouses Name:   Sally ****

Email Address:  ****@yahoo.com

Address:  ***** West Street

City:  New York

State:  NY

Zip:  14567

Primary Phone:  ***-***-0987 ext: 231

Secondary Phone:  ***-***-0144

Best Time To Contact:  Morning