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0). Email Address: ####@###.com
1). Name: #########
2). Street Address: #########
3). City: #########
4). State: New Jersey
5). Zip Code: 12345 #####
6). Day Phone: ###-###-####
7). Eve phone: ###-###-####
8). Best time for an agent to call:
9). Requesting this quote for yourself: No
10). Do you use Tobacco: Pipe
11). Height: 5 0
12). Weight: 198
13). Gender: Male
14). Date of Birth: 6/30/1955
15). Are you Self – Employed: Yes
16). If `No’, who is your employer:
17). What type of business are you employed with: Commercial
18). What is your position: Workman
19). Years with your current employer: 25 + Years
20). Occupation : Plumber
21). Present Monthly Gross Income: 4550
22). Monthly Benefit Requested: 185
23). Do you participate in any hazardous activities: Other
24). Waiting Period (time between injury and pay-out): 365 Days
25). Benefit Period: To Age 65
26). Health Problems: None
27). Medications: Yes
28). Names/doses: Clarinex
29). Family member with Heart Disease/Cancer: Yes
30). Describe: No cancer