EMAIL INDIVIDUAL QUOTE REQUEST

<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>EMAIL INDIVIDUAL QUOTE REQUEST</I></div> <div> Complete and send by email, the following information to request your personal quote or an application and brochure. Indicate Life, Disability, LTC, Critical Illness, Medical, Dental, Individual Prescription Benefit, Annuity and <B>Short Term Medical</B> in the Insurance Type and Amount area, plus your preferred method of receiving the quote. Mail, fax, email attachment or a call for appointment.</div> <bR> <div>  <form action="http://formmail.trellix.com/servlets/TlxMailer" method="POST" enctype="application/x-www-form-urlencoded"><input type="hidden" name="tlx_SortOrder" value="Your Name,Street Address,City,State,Zip,Phone,Fax and/or Email,Your Date of Birth,Insurance Type and Amount"><input type="hidden" name="tlx_FormIndex" value="2"><input type="hidden" name="tlx_OKMessage" value="Thank you for your request for information."><input type="hidden" name="tlx_SendMode" value="1"><input type="hidden" name="tlx_Subject" value="A request form was submitted"><input type="hidden" name="tlx_EmailTo" value="vealbs@juno.com"> <table cellpadding="0" cellspacing="1" border="0" align="center"> <tr> <td align="left">Your Name:<br> <input type="text" name="Your Name" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Street Address:<br> <input type="text" name="Street Address" size="30" maxlength="100"></td> </tr> <tr> <td align="left">City:<br> <input type="text" name="City" size="30" maxlength="100"></td> </tr> <tr> <td align="left">State:<br> <input type="text" name="State" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Zip:<br> <input type="text" name="Zip" size="10" maxlength="10"></td> </tr> <tr> <td align="left">Phone Number:<br> <input type="text" name="Phone" size="14" maxlength="14"></td> </tr> <tr> <td align="left">Fax and/or Email:<br> <input type="text" name="Fax and/or Email" size="20" maxlength="30"></td> </tr> <tr> <td> <input type="checkbox" name="Your Date of Birth" value="yes"> Your Date of Birth</td> </tr> <tr> <td align="left">Insurance Type and Amount:<br> <textarea name="Insurance Type and Amount" rows="10" cols="40"></textarea></td> </tr> <tr> <td align="right"><input type="reset"> <input type="submit" value="Send" name="tlx_send"></td> </tr> </table> </form>  </div> </td> </tr></table></body>