James Wm. Harris III - Medicare Products, Final Expense, Mortgage Protection, Annuities
                                          CONTACT ME 
Please call me (see 'About Me' page) or complete form below.
The minimum requested information is -
      Name, phone, and email...
      The additional information would be most helpful, however,
           and will expedite my service to you.
                                             THANK YOU! 
Client Data Sheet
First and Last Name
City and State
Phone number
Date of Birth --- Sex
Tobacco user? YES / NO
Meds currently taken (and dosages), for what condition, and what year diagnosed.
Height / weight
FOR DISABILITY ONLY: Occupation / duties; NET monthly income (self-employed); GROSS monthly income (if employee)
Any comments you wish to add
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