"client_name","agent_name","agent_address","day","evening","cell","fax","agent_email","dob_mm","dob_dd","dob_yy","sex","feet","inches","weight","smoker","insurance_amount","insurance_type","additional_insured","other_company_mm","other_company_yy","other_company","rating","rated_table","bladder","breast","cervical","colon_rectal","hodgkin","melanoma","prostate","skin","checkbox26","skin_cancer_type","where_cancer_located","diagnosis_mm","diagnosis_yy","tumor_state","treatment1","treatment2","treatment3","treatment4","treatment_other","last_treated_mm","last_treated_yy","recurring","recurrance_mm","recurrance_yy","other_illnesses","medication","dukes_scale","clarks_level","gleasons_grade","dead_relatives","relative_relationship1","relative_death_cause1","relative_relationship2","relative_death_cause2","relative_relationship3","relative_death_cause3","additional_info","Submit"
"Hattie Cole","1450 King ave","indianapolis, IN 46250","317-278-2226","317-638-3743","","","hattiepc@earthlink.com","06","06","1946","M","5'","8""","115","no","100,000","Term","","","","","declined","","","yes","","","","","","","","breast","no","04","03","1","surgical","chemotherapy","","","","12","03","no","","","no","ni","select one","select one","select one","yes","sister","cancer","Relationship","","Relationship","","","Submit"
"DAVID","BERLIN","GREENSBURG, PA  15601","7248374243","","","","dcbtlk@peoplepc.com","01","04","1963","M","6'","3""","185","no","50000","Term","","","","NONE","declined","","","","","yes","","","","","","","","10","2003","select one","surgical","chemotherapy","radiation","","","01","2004","no","","","","","B1","select one","select one","no","Relationship","","Relationship","","Relationship","","","Submit"