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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 Life 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

The Facts About Long Lerm Care Insurance: What Everyone Over 50 Should Know:

You are taking an important step towards securing the financial future for you and your family. Your greatest financial risk today and in the foreseeable future is not your hospital or doctor bills, but the very high cost of long term care.

Over 40% of all Americans over the age of 65 will spend some time in a nursing home due to a prolonged illness or disability. That's almost one out of two. Your risk of needing long term care is probably much greater than you realize.

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

 

City

 

State

 

Zip Code

 

Day Phone

 

Evening Phone

 

E-mail Address

 

Best time to call:

 

Who is this quote for?

 

Gender

 

Birthday (mm/dd/yy)

  19

Height

feet inches

Weight

lbs.

Name of parent (if different)
(otherwise, leave blank)

 

Are you married?

Yes     No 

Do you smoke?

Yes     No 

Are you diabetic?

Yes     No 

Are you insulin-dependent?

Yes     No 

Do you use:

  cane
  walker
  wheel chair

If you use other medical
equipment, please describe
(otherwise, leave blank)

 

If you've required assistance with your everyday activities in the past 2 years please explain.
(otherwise, leave blank)

 

In the past 5 years, have you:

  been confined to a hospital/nursing home
  had home care
  had long term care
  recieved rehabilitation

If you have any particular health problems, please describe
(otherwise, leave blank)

 

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

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

 

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