Auto

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" colspan=2 height=110 BGCOLOR="#999933" TEXT="#080000" bgproperties="fixed" background="038006e0ddwnfv.png"> <div> <FONT SIZE="5" COLOR="#FFFFFF" FACE="Arial" ><B>A Full-service Internet Insurance Agency selling life, auto and home insurance.    </B></FONT><B> </B></div> <div> <B>         </B><A HREF="index.htm" TARGET="_top" TITLE="A Fullservice Internet Insurance Agency "><U><B>home</B></U></A><B>   /  </B><B>  </B><A HREF="id3.htm" TARGET="_top" TITLE="Products"><U><B>Products</B></U></A><B>  /   </B><A HREF="id2.htm" TARGET="_top" TITLE="About Us"><U><B> About Us</B></U></A><B>  /  </B><A HREF="id4.htm" TARGET="_top" TITLE="Whats New"><U><B>What's New</B></U></A><B>  /  </B><A HREF="id5.htm" TARGET="_top" TITLE="Charities"><U><B>Charities</B></U></A><B>  / </B><A HREF="id16.htm" TARGET="_top" TITLE="Directors"><U><B> Directors</B></U></A><B>  /  </B><A HREF="id6.htm" TARGET="_top" TITLE="Contact Us"><U><B>Contact Us</B></U></A><B> </B></div> <div> </div> </td> </tr><tr> <td valign="top" width=160 BGCOLOR="#CCCC99" TEXT="#080000" background="040a0c00esnpes.png"> <div> <B>Auto</B></div> <div> <A HREF="id8.htm" TARGET="_top" TITLE="Home"><U>Home</U></A></div> <div> <A HREF="id9.htm" TARGET="_top" TITLE="Life"><U>Life</U></A></div> <div> <B>Auto Insurance protects you from loss due to an auto accident as well as damage from theft, vandalism or natural disaster.</B></div> </td> <td valign="top" height=370 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <B>Please complete the following to get an Auto Quote:</B></div> <bR> <div> <I>Driver Information</I></div> <bR> <div> <I> <form action="http://formmail.trellix.com/servlets/TlxMailer" method="POST" enctype="application/x-www-form-urlencoded"><input type="hidden" name="tlx_SortOrder" value="FirstName,LastName,Email,Company,Address1,Address2,City,State,Zip,Phone,Fax,Comments,Vehicle Information"><input type="hidden" name="tlx_FormIndex" value="2"><input type="hidden" name="tlx_OKMessage" value="Thank you for your request for a quote. Within 24 hours mon-Fri your quote should arrive by E-Mail."><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="charitableinsurance@comcast.net"> <table cellpadding="0" cellspacing="1" border="0" align="center"> <tr> <td align="left">First and Last name include Mr., Mrs. or Ms.:<br> <input type="text" name="FirstName" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Date of birth:<br> <input type="text" name="LastName" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Email:<br> <input type="text" name="Email" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Drivers License number:<br> <input type="text" name="Company" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Vehile Identification number:<br> <input type="text" name="Address1" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Address Include city,state, and Zip:<br> <input type="text" name="Address2" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Personal or Business use:<br> <input type="text" name="City" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Do you garage?:<br> <input type="text" name="State" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Security Alarm?:<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">Air bag?:<br> <input type="text" name="Fax" size="14" maxlength="14"></td> </tr> <tr> <td align="left">In this section please tell us the following-Auto seat belts?,ABS Brakes?,Miles to work one way?,Annual Miles?,Primary driver?,deductible-Comprehensive? and Collison?, property Damage?,Uninsured Motorist protection?,Bodily Injury?:<br> <textarea name="Comments" rows="5" cols="30"></textarea></td> </tr> <tr> <td align="left">Vehicle information-Model?,Make?,year?,Doors?,4wd?:<br> <input type="text" name="Vehicle Information" size="30" maxlength="100"></td> </tr> <tr> <td align="right"><input type="reset"> <input type="submit" value="Send" name="tlx_send"></td> </tr> </table> </form>  </I></div> <bR> <div>                                                                            </div> <div>  </div> </td> </tr></table></body>