REQUEST FOR QUOTE

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" colspan=2 height=90 BGCOLOR="#006699" TEXT="#080000" bgproperties="fixed" background="039285a1erlcgo.png"> <div> <FONT SIZE="5" COLOR="#FFCC66" FACE="Arial" ><B>LIFE, DISABILITY, MEDICAL, MEDIGAP, DENTAL, LTCI and ANNUITIES </B></FONT><B>     |     </B><A HREF="index.htm" TARGET="_top" TITLE="LIFE, DISABILITY, MEDICAL, MEDIGAP, DENT"><U><B>home</B></U></A></div> <div>                                                   </div> <div> </div> </td> </tr><tr> <td valign="top" width=210 BGCOLOR="#FFCC66" TEXT="#080000" background="038d2c00dkelyh.png"> <bR> </td> <td valign="top" height=390 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <I>REQUEST FOR QUOTE</I></div> <bR> <div> <B>PRINT A COPY OF THIS FORM, COMPLETE THE FORM AND FAX IT TO</B></div> <div> <B>1 775 542 0808 OR YOU MAY CLICK "</B><A HREF="mailto: vealbs@juno.com" TARGET="_top" TITLE="mailto: vealbs@juno.com"><U><B>mailto: vealbs@juno.com</B></U></A><B>" TO SEND AN </B></div> <div> <B>EMAIL. YOU WILL NEED TO INCLUDE THE COMPLETED INFORMATION.</B></div> <bR> <div> <B>W. FORREST VEAL, CLU</B></div> <div> <B>VEAL BENEFIT SERVICES INC.</B></div> <bR> <bR> <div> <B>NAME ____________________________DOB__________HT._____WT._____</B></div> <bR> <div> <B>SPOUSE __________________________DOB__________HT._____WT._____</B></div> <bR> <div> <B>ADDRESS ______________________________________________________</B></div> <bR> <div> <B>CITY, STATE, ZIP _________________________________________________</B></div> <bR> <div> <B>TELEPHONE _________________________FAX________________________</B></div> <bR> <div> <B><U>COMPLETE FOR THE COVERAGES TO QUOTE</U></B></div> <bR> <div> <B>LIFE INSURANCE AMOUNT $_____________TERM _____PERMANENT____</B></div> <bR> <div> <B>DISABILITY INCOME AMT. $____________(MAX. IS ABOUT 60% OF INCOME)</B></div> <bR> <div> <B>DENTAL PLAN - ___INDEMNITY  ___ POS/PPO ___DHMO ___DISCOUNT</B></div> <bR> <div> <B>LONG TERM CARE DAILY BENEFIT $___________ BENEFIT PD. _________</B></div> <bR> <div> <B>MEDICAL PLAN - PPO ____ HMO ____ AGES OF CHILDREN ___________)</B></div> <bR> <div> <B>SELF-EMPLOYED MSA PLAN - AGES OF CHILDREN, IF ANY_____________)</B></div> <bR> <div> <B>MEDICARE SUPPLEMENT PLAN (A THRU J) _________________________</B></div> <bR> <div> <B>CRITICAL ILLNESS MAX. BENEFIT - $25,000____$50,000____$100,000____</B></div> <bR> <div> <B>ANNUITY SINGLE PREMIUM AMT. $_____________QUALIFIED ___ NQ ____</B></div> <bR> <div> <B>BEST TIME TO CALL FOR ANY CONFIDENTIAL INFORMATION, IF NEEDED.</B></div> <div> <B>MORNING ______, AFTERNOON _______, EVENING _______.</B></div> <bR> <bR> <div> <B>VBS-QRF</B></div> </td> </tr></table></body>