Lead Type: Health Insurance
Date Received: 01/09/2006

Contact Infomation:
Name: Blair Rice
Address: 25 Heartford Place
City: Adairsville
State: GA
Zip: 30103
Primary Phone: (770) 877-4610 Day,Evening
Alternate Phone: (678) 676-9622 Day,Evening
Email: ricetrucking987@aol.com

Insured Information:
Sex dob Height Weight
----- ---------- ---------- ---------
Primary: Female 05/28/1971 5'7" 130
Spouse: Male 07/22/1970 5'11" 180
Child 1: Male 09/02/1993
Child 2: Male 11/15/1994
Child 3: Female 10/06/1997
Child 4: Male 07/22/2004

Insureds that currently use tobacco: My spouse
Currently Insured: No
If insured, carrier name:
Self Employed: No
Occupation: my husband is a truck driver

Policy Information:
Full Time Student: No
Duration of Coverage needed: ASAP
Diabetes: No
Date Coverage needed: as soon as possible

Health Conditions, Medications, and Other Information:

Is anyone to be covered currently pregnant? No

Other Health Conditions and Information:
Asthma
The youngest child has asthma.He was diagnosed at 2 months and is on singulair, abuterol and pulmicort(daily).He is also on Orapred or Predisone when needed.

I do have another son d.o.b. 03/16/1997. He also has asthma and is on the same medication as his younger brother, however he is covered on Georgia Medicaid at this time.