Request free REAP plan -- 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> <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_solutions_.htm" TARGET="_top" TITLE="Seniors"><U><B>Back</B></U></A></div> <bR> <bR> <bR> <bR> </td> <td valign="top" colspan=2 height=85 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <B>Request free REAP plan -- 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 <I>Retirement Earnings & Assets Protector </I>™ (REAP™) plan-design is a <I><B>free service</B></I> and customized to fit your personal needs and goals in protecting your assets and income from the greatest threat -- costs of long-term care.</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,Phone,Time to call,Health 1,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 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">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">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">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> </td> </tr><tr> <td valign="top" colspan=2 height=32 BGCOLOR="#FFFFFF" TEXT="#080000"> <div> <IMG BORDER="0" SRC="1x1.gif" HEIGHT="17" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" WIDTH="17"><B> </B><IMG BORDER="0" SRC="1x1.gif" HEIGHT="17" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" WIDTH="17"><B>     </B><A HREF="long_term_care_insurance_solutions_.htm" TARGET="_top" TITLE="Seniors"><U><B><IMG SRC="04011110.png" border=0 width="17" height="17" ALT="up" ALIGN="BOTTOM" HSPACE="0" VSPACE="0"></B></U></A><B> </B><IMG BORDER="0" SRC="1x1.gif" HEIGHT="17" ALIGN="BOTTOM" HSPACE="0" VSPACE="0" WIDTH="17"></div> <bR> </td> </tr></table></body>