Let Us Analyze Your Current Life Insurance Policies

<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><A HREF="id2.htm" TARGET="_top" TITLE="About Us"><U><B>About Us</B></U></A><B>  / </B><A HREF="id3.htm" TARGET="_top" TITLE="Products"><U><B> Products</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></div> <div>  </div> <div> </div> </td> </tr><tr> <td valign="top" width=190 BGCOLOR="#CCCC99" TEXT="#080000" background="039bec00esnpes.png"> <div> <B>Help us support people with special needs and we will help you meet your estate planning needs. A win win model that puts a premium on people. </B></div> </td> <td valign="top" height=370 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> Let Us Analyze Your Current Life Insurance Policies</div> <div> Please fill in the form below</div> <div> Please Note we currently only doing business in MA</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="FirstName,LastName,Email,Company,Address1,Address2,City,State,Zip,Phone,Fax,Comments,[Custom]"><input type="hidden" name="tlx_FormIndex" value="2"><input type="hidden" name="tlx_OKMessage" value="Thank you for your request for information. Please give us several days to make an analysis. thank you"><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@mediaone.net"> <table cellpadding="0" cellspacing="1" border="0" align="center"> <tr> <td align="left">Full Name:<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">Smoking Status ( Nonsmoker, Smoker, Smoked but quit 3 years ago):<br> <input type="text" name="Company" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Full address including zip:<br> <input type="text" name="Address1" size="30" maxlength="100"></td> </tr> <tr> <td align="left">type of Policy ( Term, Whole life, Universal life, etc.):<br> <input type="text" name="Address2" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Face amount:<br> <input type="text" name="City" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Cash Value if any:<br> <input type="text" name="State" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Policy #:<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">Comments- Please include your particular circumstances):<br> <textarea name="Comments" rows="7" cols="30"></textarea></td> </tr> <tr> <td align="left"> Company or Companies and current annual premium:<br> <input type="text" name="[Custom]" 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>  </div> <bR> </td> </tr></table></body>