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With LeadExchange™ working for you, you'll have confidence that the leads that your web site produces are only from interested consumers.  Below you'll find a sample Health Insurance lead.  All consumers are required to fill out a standardized questionnaire in order to be considered a valid lead.  To return, please click here

Today, with health care costs rising dramatically each year, even relatively simple medical procedures can run into the thousands of dollars.

However, it is not just the cost of medical care that is rising. The variety of care available is also increasing.

In order to reduce the risk of unexpected health care costs, private health insurance companies now offer an array of health insurance programs and plans, that vary widely in terms of coverage, costs and benefits

Instructions:  Please fill in this form as completely as possible in order to ensure that your quote will be as accurate as possible.

First Name


Last Name


Street Address






Zip Code


Day Phone


Evening Phone


E-mail Address


Best time to call:


Who is this quote for?




Birthday (mm/dd/yy)



feet inches



How many dependents do you have?


How old are those dependents


Do you or any of your dependents use any tobacco products?


Please describe your
particular health problems:
(leave blank if none)


Please list any medications and dosage
(leave blank if none)


Your occupation?


Your current insurance company?


What type of plan do you currently have?


How much are you paying per month?


Would you like an additional quote for any of the following insurance products?

 Life Insurance
 Annuities (Retirement Vehicle)
 Disability Insurance
 Long Term Care Insurance
 Group Health Insurance
 Auto Insurance
 Homeowners Insurance
 Home Loans