Alpha 360
803Fox
Original URL
Caller Number
First Name
Last Name
Birth Date
Address
City
State
Select an option
AL
AK
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip Code
Email Address
IP Address
Jornaya Lead ID
Gender
Select an option
Male
Female
Product
Select an option
Medicare Original (MO)
Medicare Advantage (MA)
Medicare Part D (MD)
Medicare Supplement (MS)
Relationship to Applicant
Select an option
Self
Spouse
Child
Sibling
Parent
Grandparent
Grandchild
Other
Household Income
Select an option
Below $30,000
$30,000 - $44,999
$45,000 - $59,999
$60,000 - $74,999
Above $75,000
Household Size
First Time Buyer
Select an option
Yes
No
Source
Session Length
TCPA Text
Conditions
High Cholesterol:
Yes
No
Pulmonary Disease:
Yes
No
Vascular Disease:
Yes
No
AIDS/HIV:
Yes
No
Kidney Disease:
Yes
No
Asthma:
Yes
No
Cancer:
Yes
No
Depression:
Yes
No
Diabetes:
Yes
No
Heart Disease:
Yes
No
Liver Disease:
Yes
No
High Blood Pressure:
Yes
No
Mental Illness:
Yes
No
Stroke:
Yes
No
Alzheimer:
Yes
No
Alcohol Abuse:
Yes
No
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