<html><head><title>Insurance</title><style>td {font-family:
arial}</style></head>
<body bgcolor=#FDF5E6><div align=center style=font-family:times><font size=+3
color=red>Save up to 70% on your Life Insurance!</font><br><font size=+2>Why
Spend More Than You Have To?</font><br>Check out these example monthly rates...
<br>10-year level premium term insurance<br>(20 and 30 year rates also
available)</div><table width=500 align=center bgcolor=white><tr><td></td><td
colspan=2 align=center>$250,000</td><td colspan=2 align=center>$500,
000</td><td colspan=2 align=center>$1,000,000</td></tr><tr bgcolor=#003366><td
style=color:white>Age</td><td style=color:white>Male</td><td
style=color:white>Female</td><td style=color:white>Male</td><td
style=color:white>Female</td><td style=color:white>Male</td><td
style=color:white>Female</td></td></tr><tr><td>30</td><td>$12</td><td>$11</td><
td>$19</td><td>$15</td><td>$31</td><td>$27</td></tr><tr><td>40</td><td>$15</td>
<td>$13</td><td>$26</td><td>$21</td><td>$38</td><td>$37</td></tr><tr><td>50</td
><td>$32</td><td>$24</td><td>$59</td><td>$43</td><td>$107</td><td>$78</td></tr>
<tr><td>60</td><td>$75</td><td>$46</td><td>$134</td><td>$87</td><td>$259</td><t
d>$161</td></tr></table><div align=center>(Smoker rates also
available)<p><font size=+1>Take a minute to fill out the simple form below and
receive a FREE quote<br>comparing the best values from among hundreds of the
nation's top insurance companies!</font></div><hr size=1><table><td><form
action='mailto: ?subject=insurance' method=post
enctype=text/plain>*All Fields required</td></tr><td>First
Name:</td><td><input name=first_name tabindex=1></td></tr><tr><td>Last
Name:</td><td><input name=last_name
tabindex=2></td></tr><tr><td>Address:</td><td><input name=address
tabindex=3></td>
</tr><tr><td>City:</td><td><input name=city
tabindex=4></td></tr><tr><td>State:</td><td><input name=state size=2
tabindex=5></td></tr><tr><td>Zip:</td><td><input name=zip_code
tabindex=6></td></tr><tr><td>Day Phone:</td><td><input name=day_phone
tabindex=7> (xxx-xxx-xxxx)</td></tr><tr><td>Evening Phone:</td><td><input
name=evening_phone tabindex=7></td></tr><tr><td>Fax:</td><td><input name=fax
tabindex=7> (xxx-xxx-xxxx)</td></tr><tr><td>Email:</td><td><input name=email
tabindex=8></td>
</tr><tr><td>Male or Female:</td><td><input name=male_or_female
tabindex=11></td></tr><tr><td>Date of Birth:</td><td><input name=date_of_birth
size=13 tabindex=11>
(mm/dd/yy)</td></tr><tr><td>Type of Insurance:</td><td><select
name=type_of_insurance size=1><option>30
Yr Guaranteed Level Term<option selected>20
Yr Guaranteed Level Term<option>15 Yr Guaranteed Level Term<option>10
Yr Guaranteed Level Term<option>Universal Life<option>2nd-to-die
(Survivorship Insurance)</select></td></tr><tr><td>Insurance
Amount:</td><td><select name=insurance_amount><option>$100,000<option>$150,
000<option>$200,000<option>$250,000<option>$300,000<option>$350,
000<option>$400,000<option>$450,000<option selected>$500,000<option>$550,
000<option>$600,000<option>$650,000<option>$700,000<option>$750,
000<option>$800,000<option>$850,000<option>$900,000<option>$950,000<option>$1,
000,000<option>$1,500,000<option>$2,000,000<option>$2,500,000<option>$3,000,
000<option>$3,500,000<option>$4,000,000<option>$4,500,000<option>$5,000,
000<option>above $5,000,000</select></td></tr><tr><td>Height:</td><td><input
name=height size=10 tabindex=12></td></tr><tr>
<td>Weight:</td><td><input name=weight size=3 tabindex=13>
lbs</td></tr><tr><td>Tobacco Use:</td><td><select name=tobacco_use size=1
tabindex=14><option selected>(Please
Select)<option>Have never smoked or used nicotine<option>Used to smoke, but
quit less than 1 yr ago<option>Used to
smoke 1-2 yrs ago<option>Used to
smoke 2-3 yrs ago<option>Used to smoke 3-5 yrs ago<option>Used to smoke over
5 yrs ago<option>Currently smoke cigarettes<option>Other
nicotine use-cigars/pipe/chew/patch</select></td></tr><tr><td>Health
Status:</td><td><select name=health_status tabindex=15><option
selected>(Please
Select)<option>Excellent: trim and athletic, no medications<option>Good:
no infirmities and no medications<option>Fair: slightly overweight
or taking medication<option>Poor: have/had a serious health
condition</select></td>
</tr><tr><td>Health conditions?<br><input name=HealthProbs type=radio
value=Yes>Yes<input checked name=HealthProbs type=radio
value=No>No</td><td>Explain:<br><textarea
name=HealthProbsDesc></textarea></td></tr><tr><td>Prescription medications?
<br><input name=TakeRx type=radio value=Yes>Yes<input checked name=TakeRx
type=radio value=No>No</td><td>Explain:<br><textarea
name=TakeRxDesc></textarea></td></tr><tr><td>Do you engage in any hazardous
activities?<br>(i.e. scuba,skydiving,private pilot,etc.)<br><input
name=HazAvocOcc type=radio value=Yes>Yes<input checked name=HazAvocOcc
type=radio value=No>No</td><td>Explain:<br><textarea
name=HazAvocOccDesc></textarea></td></tr><tr><td>Did your parents or siblings
have<br> heart disease or cancer prior to age 60?<br><input name=FamilyHistory
type=radio
value=Yes>Yes<input checked name=FamilyHistory type=radio
value=No>No</td><td>Explain:<br><textarea
name=FamilyHistoryDesc></textarea></td></tr></table><div align=center><input
type=submit value="Submit Quote Request"></div><p><table><tr><td
style=font-size:10pt>We will open your email application to submit your
inquiry. All quotes will be from insurance companies rated A-, A, A+ or A++ by
A.M. Best. Actual premiums and coverage availability will vary depending upon
age, sex, state, health history and tobacco use. THIS IS NOT AN OFFER OR
CONTRACT TO BUY INSURANCE PRODUCTS, but rather a confidential informational
inquiry. All information submitted is strictly confidential, and will be given
to an insurance professional, licensed in your state of residence, who will
contact you and provide your quote directly. Further transmissions of this
email may be stopped at no cost to you. <a href="mailto: .
org">PLEASE CLICK HERE</a> AND TYPE REMOVE.</td></tr></table></body></html>
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