LeadExchange - Insurance and Mortgage Leads. Your web site will never generate a bad lead again!

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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 Group 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
City
State
Zip Code
Day Phone
Evening Phone
E-mail Address
Your Birthday (mm/dd/yy)	19
Best time to call:

Employee / Family Member 1

Employee Name	M/F	Age	Status

Occupation	Salary	Currently Insured?	Plan type
	$

Employee / Family Member 2

Employee Name	M/F	Age	Status

Occupation	Salary	Currently Insured?	Plan type
	$

Employee / Family Member 3

Employee Name	M/F	Age	Status

Occupation	Salary	Currently Insured?	Plan type
	$

Employee / Family Member 4

Employee Name	M/F	Age	Status

Occupation	Salary	Currently Insured?	Plan type
	$

Employee / Family Member 5

Employee Name	M/F	Age	Status

Occupation	Salary	Currently Insured?	Plan type
	$

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

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


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