<form name=contactus method="POST" action="contactus.php" target=_self onsubmit="return formCheck(this);">
<tr><td align="left"><font size="2">First Name</font></td>
<td align="left"><input name="First Name" value size="35" maxlength=16 value=""></td></tr>
<tr><td align="left" height="24"><font size="2">Last Name</font></td>
<td align="left" height="24"><input type="text" name="Last name" size="35" maxlength=32 value=""></td></tr>
<tr><td align="left"><font size="2">Company</font></td>
<td align="left"><input type="TEXT" name="Company" value size="35" maxlength=32 value=""></td></tr>
<tr><td align="left"><font size="2">Street Address</font></td>
<td align="left"><input type="text" name="Street" size="35" maxlength=32 value=""></td></tr>
<tr><td align="left"><font size="2">City</font></td>
<td align="left"><input type="text" name="City" size="35" maxlength=20 value=""></td></tr>
<tr><td align="left"><font size="2">State</font></td>
<td align="left"><input type="text" name="State" size="35" maxlength=2 value=""></td></tr>
<tr><td align="left"><font size="2">Zip Code</font></td>
<td align="left"><input type="text" name="ZipCode" size="35" maxlength=5 onblur= valzip(); value=""></td></tr>
<tr><td align="left"><font size="2">Policy Number</font></td>
<td align="left"><input type="text" name="Policy" size="35" maxlength=16 value=""></td></tr>
<tr><td align="left"><font size="2">Daytime Phone</font></td>
<td align="left"><input type="TEXT" name="Telephone" value size="35" maxlength=16 value=""></td></tr>
<tr><td align="left"><font size="2">E-mail</font></td>
<td align="left"><input type="TEXT" name="Email" value size="35" maxlength=40 value=""></td></tr>
</table>
</td>
<td width="303" colspan="2">
<p align="left">
I am a/an :</p></td>
</tr>
<tr>
<td width="303" colspan="2">
<SELECT NAME="Iam">
<OPTION>Prospective insured</option>
<OPTION>Prospective agent</option>
<OPTION>Insured</option>
<OPTION>Agent</option>
<OPTION>Uknown Person</option>
</SELECT></td>
</tr>
<tr>
<td width="303" colspan="2">
<font size="2">I wish to :
</font></td>
</tr>
<tr>
<td width="303" colspan="2">
<select name="WishTo">
<OPTION>Request Claim Information</option>
<OPTION>Request information about my policy</option>
<OPTION>Request information about obtaining my policy</option>
<OPTION>Request my password</option>
<OPTION>Comment on your website</option>
<OPTION>Contact you on an unlisted topic</option>
</select></td>
</tr>
<tr>
<td width="303" colspan="2">
<font size="2">Message/Question</font> <!--<input type=text name=Comments size=35>--></td>
</tr>
<tr>
<td width="303" colspan="2">
<textarea name="comment" rows="9" cols="50" maxlength=800 value=""></textarea></td>
</tr>
<tr>
<td width="303" colspan="2">
<font size="2">User Verification: 1 + 2 =</font> <input type=text size=2 name=verify></td>
</tr>
<tr>
<td width="63">
<input type="submit" onSubmit="return checkmail(this)" value="Submit" name="B1"></td>
<td width="236">
<input type="reset" value="Cancel" name="B2"></td>
</tr>
</table>
</form>
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