Marc,
Here is a sample of the demo form--
Demographic Information
Last Name x
First Name x
Middle Initial x
Gender Male
Date of Birth 08/19/2013
Address x
City xx
State xx
Zip Code xxx
Home Phone skipped
Cell Phone skipped
Work Phone skipped
E-Mail Address skipped
Best Way to Contact
Me
skipped
Name of Emergency
Contact
x
Phone Number of
Emergency Contact
x
Insurance Information
Primary Insurance skipped
Policy Number skipped
Secondary/
Supplemental
Insurance
skipped
Policy Number skipped
Name of Policy Holder skipped
Date of Birth of Policy
Holder
