Request free Asset-Transfer -- for long-term care funding solutions

<body topmargin=0 leftmargin=0 marginheight=0 marginwidth=0> <table cellpadding=0 cellspacing=0 border=0><tr> <td valign="top" rowspan="3" width=160 BGCOLOR="#000099" TEXT="#F7F7FF" background="043acc00erkqpg.png"> <bR> <bR> <bR> <bR> <bR> <bR> <div> <B>(804) 744-8512</B></div> <bR> <bR> <bR> <bR> <bR> <bR> <bR> <bR> <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> <div> <A HREF="long_term_care_insurance_quotes_personalized_and_free.htm" TARGET="_top" TITLE="Our Programs and Services"><U><B>Back</B></U></A></div> <bR> </td> <td valign="top" colspan=2 height=85 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <B>Request free Asset-Transfer -- for long-term care funding solutions</B><B> </B></div> <div> </div> </td> </tr><tr> <td valign="top" height=363 colspan=2 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <IMG BORDER="0" SRC="Symb075c00b7011800000000.png" HEIGHT="19" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Our Asset-Transfer alternative plan review is a <I><B>free service</B></I> that will be customized to meet your needs and wants in funding for long-term care and as an alternative to regular long-term care insurance</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">Please take a moment to complete and submit your request for information below. There is no obligation.</div> <div> <IMG BORDER="0" SRC="Symb075c00b700f000000000.png" HEIGHT="16" WIDTH="24" ALIGN="bottom" HSPACE="0" VSPACE="0">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> <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,Do you use Tobacco,Spouse Name,Spouse Age,Does spouse use Tobacco,Exisiting Annuity,Other Assets,Address1,City,State,Zip,Phone,Time to call,MailingList,Comments"><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="Request for Asset-Transfer 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">Do you use Tobacco:<br> <input type="text" name="Do you use Tobacco" size="14" maxlength="14"></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">Does spouse use Tobacco:<br> <input type="text" name="Does spouse use Tobacco" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Existing Annuity Value (approx):<br> <input type="text" name="Exisiting Annuity" size="30" maxlength="100"></td> </tr> <tr> <td align="left">Amount of CDs, Money Market, Bond funds, etc. (approx):<br> <input type="text" name="Other Assets" 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 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> <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> </td> </tr><tr> <td valign="top" colspan=2 height=32 BGCOLOR="#FFFFFF" TEXT="#080000"> <bR> <bR> </td> </tr></table></body>