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Applicant Information: ID# 837223
Name: XXXX XXXXXXXX Gender: XXXXXXXX Birth date: 12/14/48
Address: XXXXX XXXXXXXXXX XXXX City: Orchard Park State: New York Zip: XXXXX
Work Phone: XXX-XXX-XXXX Home Phone: XXX-XXX-XXXX Best Time To Call: 8-20 a.m.
E-mail Address: xxxxxxxx@earthlink.net

Quote Information:	Employment Information:
Are you requesting for yourself? Yes	Occupation: Self employed
If no, who is request for? Me

Health Information:	Policy Information:
Do you use Tobacco: No	Your current insurance company: Golden Rule
What type of tobacco products: N/A	What type of plan do you currently have? HMO
Height: 6' 3"	How much are you paying per month? $689.00
Weight: 201	How many dependents do you have? 3
Health Problems: Blood Pressure	How old are those dependents? 13, 9, 6
Medications: None