Quote Request for Children Insurance

<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"> <div> Veal Benefit Services Inc.</div> <div> W. Forrest Veal, CLU</div> <div> P. O. Box 700222</div> <div> Dallas, TX 75370</div> <div> 972 250 6516</div> <div> 1 888 845 8325</div> <div> Fax 1 775 542 0808</div> <div> E-mail - vealbs@juno.com</div> </td> <td valign="top" height=390 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <I>Quote Request for Children Insurance</I></div> <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,Address,City,State,Zip,Phone,Fax,Email,Child's Name,Child's Date of Birth,Child's Height and Weight,Life or Medical Insurance"><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">Address:<br> <input type="text" name="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">Child's Name:<br> <input type="text" name="Child's Name" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Child's Date of Birth:<br> <input type="text" name="Child's Date of Birth" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Child's Height and Weight:<br> <input type="text" name="Child's Height and Weight" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Life or Medical Insurance:<br> <textarea name="Life or Medical Insurance" rows="5" cols="30"></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>