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<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0 height="100%"><tr> <td valign="top" width=170 BGCOLOR="#000099" TEXT="#F7F7FF" background="043aac00erkqpg.png"> <bR> <bR> <bR> <bR> <bR> <bR> <div> <B>(804) 744-8512</B></div> <bR> <bR> <bR> <bR> <bR> <bR> <div> <A HREF="long_term_care_insurance_solutions.htm" TARGET="_top" TITLE="Contact Us"><U><B>Contact Us</B></U></A></div> <bR> <bR> <bR> <bR> <bR> <bR> </td> <td valign="top" BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <FONT SIZE="5" COLOR="#000066" FACE="Arial" ><B>Long-term care funding solutions by Financial Strategies </B></FONT>     |    <FONT SIZE="3" COLOR="#000099" FACE="Arial" > <A HREF="index.htm" TARGET="_top" TITLE="Longterm care funding solutions by Finan"><U>home</U></A></FONT></div> <bR> <div> <I>Request free "safe money" review</I></div> <bR> <bR> <bR> <div> Our <I>review</I> and plan-design is a <I><B>free service</B></I> and customized to fit your personal needs and goals in protecting your retirement assets and income. If you currently own an annuity, you can also receive a free Annuity Review<FONT SIZE="3" COLOR="#000000" FACE="Arial" >™ checkup</FONT> </div> <div>  Please take a moment to complete and submit your request for information below. There is no obligation.</div> <div> All information is held in the strictest of confidence. You need not worry about your privacy because we do not willfully use, sell or disclose your personally identifiable information unless you give us permission to do so or unless we are required to do so by law.</div> <bR> <bR> <bR> <bR> <bR> <div> <I> <form action="http://csbmail.globalscape.com/cgi-bin/csbmail/csbmail.pl" method="POST" enctype="application/x-www-form-urlencoded"><input type="hidden" name="tlx_SortOrder" value="FirstName,LastName,Email,Current Age,Spouse Name,Spouse Age,Phone,Time to call,Health 1,Own annuities,Address1,City,State,Zip,MailingList,Comments"><input type="hidden" name="tlx_FormIndex" value="2"><input type="hidden" name="tlx_OKMessage" value="Thank you for your request for a free plan-design."><input type="hidden" name="tlx_SendMode" value="1"><input type="hidden" name="tlx_Subject" value="Request for a REAP was submitted"><input type="hidden" name="tlx_EmailTo" value="fsireap@covad.net"> <table cellpadding="0" cellspacing="1" border="0" align="center"> <tr> <td align="left">First Name:<br> <input type="text" name="FirstName" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Last Name:<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">Current Age:<br> <input type="text" name="Current Age" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Spouse's Name:<br> <input type="text" name="Spouse Name" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Spouse's Age:<br> <input type="text" name="Spouse Age" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Phone Number:<br> <input type="text" name="Phone" size="14" maxlength="14"></td> </tr> <tr> <td align="left">Time to call:<br> <input type="text" name="Time to call" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Do you or your spouse have any health conditions or take medications? Please explain under Comments::<br> <input type="text" name="Health 1" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Do you own any annuities?:<br> <input type="text" name="Own annuities" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Street Address :<br> <input type="text" name="Address1" 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> <input type="checkbox" name="MailingList" value="yes"> Add me to your mailing list</td> </tr> <tr> <td align="left">Comments:<br> <textarea name="Comments" 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>  </I></div> <bR> <bR> </td> </tr></table></body>