EMAIL OCCUPATIONAL ACCIDENT 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 OCCUPATIONAL ACCIDENT QUOTE REQUEST</I></div> <div> Complete the following information and submit by email to obtain a quote for your company. </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="Contact Name,Business Name,Street Address,City,State,Zip,Phone,Fax,Email,Type of Business and SIC if known,No. of Employees by Job Description plus Monthly Payroll"><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">Contact Name:<br> <input type="text" name="Contact Name" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Business Name:<br> <input type="text" name="Business 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 Number:<br> <input type="text" name="Fax" size="14" maxlength="14"></td> </tr> <tr> <td align="left">Email:<br> <input type="text" name="Email" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Type of Business and SIC if known:<br> <input type="text" name="Type of Business and SIC if known" size="30" maxlength="100"></td> </tr> <tr> <td align="left">No. of Employees by Job Description plus Monthly Payroll:<br> <textarea name="No. of Employees by Job Description plus Monthly Payroll" rows="5" cols="50"></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>