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<DIV align="center"><FONT face="Arial, Helvetica, sans-serif" size="2"><U><A href="../guide/index.htm">Life
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<TD height="4" width="425"><FONT size="2" face="Verdana, Arial, Helvetica, sans-serif"><B><FONT color="#000000"><IMG src="../../images/2x2.gif" width="10" height="12"></FONT><FONT face="Arial, Helvetica, sans-serif" size="3" color="#CCCC00"><B><FONT color="#000000">Life
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<TD height="32" valign="bottom"><B><FONT size="2" face="Arial, Helvetica, sans-serif">Disclaimer</FONT></B></TD>
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<P><FONT size="2" face="Arial, Helvetica, sans-serif">This form
will allow you to obtain life quotes from many of the Country's
leading life insurance companies. But you should be aware
that 1) quotes are not guaranteed 2) all products proposed
here are medically underwritten 3) a signed application is
needed for most life insurance policies 4) the product descriptions
and underwriting guidelines on this site are generalized
and may not be applicable to any given policy. </FONT></P>
<P><B><FONT size="2" face="Arial, Helvetica, sans-serif">Get
a Quote</FONT></B></P>
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<P><FONT face="Arial, Helvetica, sans-serif" size="2">Complete this
form to compare life insurance rates for over 150 companies. The
ten best rates will be displayed. Be sure to consider important
policy features such as the length of time premiums are guaranteed
and convertability options. <A href="../../forms/fsd_reply_form.htm">Contact
us</A> for more information about life insurance options.</FONT></P>
<FORM action="http://www.insurancesquared.com/cgi-bin/complifeus/cqsl.cgi" method="post">
<INPUT type="hidden" name="UserLocation" value="INSURANCESERVICES/">
<TABLE summary="INSTANT ONLINE TERM QUOTE INPUT FORM" border=1 cellpadding=10 cellspacing=0 width="100%">
<TR>
<TD>
<DIV align="left"><FONT face="Verdana, Arial, Helvetica, sans-serif" size="2">
Birthdate: </FONT></DIV>
</TD>
<TD> <FONT face="Verdana, Arial, Helvetica, sans-serif"> <FONT size="2">
</FONT></FONT>
<TABLE width="100%" border="0" cellspacing="5" cellpadding="1">
<TR>
<TD height="36"> <FONT size="2" face="Verdana, Arial, Helvetica, sans-serif">
<SELECT name="BirthMonth">
<OPTION value="1">January
<OPTION value="2">February
<OPTION value="3">March
<OPTION value="4">April
<OPTION value="5">May
<OPTION selected value="6">June
<OPTION value="7">July
<OPTION value="8">August
<OPTION value="9">September
<OPTION value="10">October
<OPTION value="11">November
<OPTION value="12">December
</SELECT>
Month</FONT></TD>
</TR>
<TR>
<TD height="36"> <FONT size="2" face="Verdana, Arial, Helvetica, sans-serif">
<SELECT name="Birthday">
<OPTION>1
<OPTION>2
<OPTION>3
<OPTION>4
<OPTION>5
<OPTION>6
<OPTION>7
<OPTION>8
<OPTION>9
<OPTION>10
<OPTION>11
<OPTION>12
<OPTION>13
<OPTION>14
<OPTION>15
<OPTION>16
<OPTION>17
<OPTION>18
<OPTION>19
<OPTION>20
<OPTION>21
<OPTION>22
<OPTION>23
<OPTION>24
<OPTION>25
<OPTION>26
<OPTION>27
<OPTION>28
<OPTION>29
<OPTION>30
<OPTION>31
</SELECT>
Day <IMG src="../../images/2x2.gif" width="20" height="10">
<SELECT name="BirthYear">
<OPTION>1910
<OPTION>1911
<OPTION>1912
<OPTION>1913
<OPTION>1914
<OPTION>1915
<OPTION>1916
<OPTION>1917
<OPTION>1918
<OPTION>1919
<OPTION>1920
<OPTION>1921
<OPTION>1922
<OPTION>1923
<OPTION>1924
<OPTION>1925
<OPTION>1926
<OPTION>1927
<OPTION>1928
<OPTION>1929
<OPTION>1930
<OPTION>1931
<OPTION>1932
<OPTION>1933
<OPTION>1934
<OPTION>1935
<OPTION>1936
<OPTION>1937
<OPTION>1938
<OPTION>1939
<OPTION>1940
<OPTION>1941
<OPTION>1942
<OPTION>1943
<OPTION>1944
<OPTION>1945
<OPTION>1946
<OPTION>1947
<OPTION>1948
<OPTION>1949
<OPTION>1950
<OPTION>1951
<OPTION>1952
<OPTION selected>1953
<OPTION>1954
<OPTION>1955
<OPTION>1956
<OPTION>1957
<OPTION>1958
<OPTION>1959
<OPTION>1960
<OPTION>1961
<OPTION>1962
<OPTION>1963
<OPTION>1964
<OPTION>1965
<OPTION>1966
<OPTION>1967
<OPTION>1968
<OPTION>1969
<OPTION>1970
<OPTION>1971
<OPTION>1972
<OPTION>1973
<OPTION>1974
<OPTION>1975
<OPTION>1976
<OPTION>1977
<OPTION>1978
<OPTION>1979
<OPTION>1980
<OPTION>1981
<OPTION>1982
<OPTION>1983
<OPTION>1984
<OPTION>1985
</SELECT>
Year</FONT></TD>
</TR>
</TABLE>
</TD>
</TR>
<TR>
<TD> <FONT face="Verdana, Arial, Helvetica, sans-serif" size="2">
Sex: </FONT> </TD>
<TD>
<INPUT type="radio" checked name="Sex" value="M">
<FONT face="Verdana, Arial, Helvetica, sans-serif" size="2">Male<BR>
<INPUT type="radio" name="Sex" value="F">
Female </FONT> </TD>
</TR>
<TR>
<TD> <FONT face="Verdana, Arial, Helvetica, sans-serif" size="2">Do
You Smoke<BR>
or use tobacco?: </FONT> </TD>
<TD>
<INPUT type="radio" name="Smoker" value="Y">
<FONT face="Verdana, Arial, Helvetica, sans-serif" size="2">
Yes<BR>
<INPUT type="radio" checked name="Smoker" value="N">
No </FONT></TD>
</TR>
<TR>
<TD>
<TABLE width="100%" border="0" cellspacing="0" cellpadding="0">
<TR>
<TD><FONT face="Verdana, Arial, Helvetica, sans-serif" size="2">Describe
your<BR>
Health:</FONT></TD>
</TR>
<TR>
<TD height="28" valign="bottom"><FONT size="2" face="Arial, Helvetica, sans-serif"><A href="#" onClick="MM_openBrWindow('uw_guide.htm','uwguide','toolbar=no,location=no,status=no,menubar=no,scrollbars=yes,resizable=no')">Underwriting
Guide</A></FONT> </TD>
</TR>
</TABLE>
</TD>
<TD>
<INPUT type="radio" name="Health" value="R">
<FONT face="Verdana, Arial, Helvetica, sans-serif" size="2">
Standard<BR>
<INPUT type="radio" name="Health" value="RP">
Standard Plus<BR>
<INPUT type="radio" name="Health" value="P" checked>
Preferred<BR>
<INPUT type="radio" name="Health" value="PP">
Preferred Plus </FONT></TD>
</TR>
<TR>
<TD> <FONT face="Verdana, Arial, Helvetica, sans-serif" size="2">Your
State: </FONT> </TD>
<TD>
<SELECT name="State" size="1">
<OPTION value="1">Alabama
<OPTION value="2">Alaska
<OPTION value="3">Arizona
<OPTION value="4">Arkansas
<OPTION value="5">California
<OPTION value="6">Colorado
<OPTION value="7">Connecticut
<OPTION value="8">Delaware
<OPTION value="9">Dist. Columbia
<OPTION value="10">Florida
<OPTION value="11">Georgia
<OPTION value="12">Hawaii
<OPTION value="13">Idaho
<OPTION value="14">Illinois
<OPTION value="15">Indiana
<OPTION value="16">Iowa
<OPTION value="17">Kansas
<OPTION value="18">Kentucky
<OPTION value="19">Louisiana
<OPTION value="20">Maine
<OPTION value="21" selected>Maryland
<OPTION value="22">Massachusetts
<OPTION value="23">Michigan
<OPTION value="24">Minnesota
<OPTION value="25">Mississippi
<OPTION value="26">Missouri
<OPTION value="27">Montana
<OPTION value="28">Nebraska
<OPTION value="29">Nevada
<OPTION value="30">New Hampshire
<OPTION value="31">New Jersey
<OPTION value="32">New Mexico
<OPTION value="52">NY Non-Bus
<OPTION value="33">NY Business
<OPTION value="34">North Carolina
<OPTION value="35">North Dakota
<OPTION value="36">Ohio
<OPTION value="37">Oklahoma
<OPTION value="38">Oregon
<OPTION value="39">Pennsylvania
<OPTION value="40">Rhode Island
<OPTION value="41">South Carolina
<OPTION value="42">South Dakota
<OPTION value="43">Tennessee
<OPTION value="44">Texas
<OPTION value="45">Utah
<OPTION value="46">Vermont
<OPTION value="47">Virginia
<OPTION value="48">Washington
<OPTION value="49">West Virginia
<OPTION value="50">Wisconsin
<OPTION value="51">Wyoming
<OPTION value="53">Guam
<OPTION value="54">Puerto Rico
<OPTION value="55">Virgin Islands
<OPTION value="56">American Samoa
</SELECT>
</TD>
</TR>
<TR>
<TD> <FONT face="Verdana, Arial, Helvetica, sans-serif" size="2">Initial
Level<BR>
Insurance Period: </FONT> </TD>
<TD>
<SELECT name="Catagory" size="1">
<OPTION value="A">5 Year - Guaranteed Only
<OPTION value="2">5 Year
<OPTION value="B">10 Year - Guaranteed Only
<OPTION value="3">10 Year
<OPTION value="C">15 Year - Guaranteed Only
<OPTION value="4">15 Year
<OPTION value="D">20 Year - Guaranteed Only
<OPTION value="5" selected>20 Year
<OPTION value="E">25 Year - Guaranteed Only
<OPTION value="6">25 Year
<OPTION value="F">30 Year - Guaranteed Only
<OPTION value="7">30 Year
</SELECT>
</TD>
</TR>
<TR>
<TD> <FONT face="Verdana, Arial, Helvetica, sans-serif" size="2">Amount
of<BR>
Insurance: </FONT> </TD>
<TD>
<SELECT name="FaceAmount" size="1">
<OPTION value="50000">$50,000
<OPTION value="75000">$75,000
<OPTION value="100000">$100,000
<OPTION value="150000">$150,000
<OPTION value="200000">$200,000
<OPTION value="250000" selected>$250,000
<OPTION value="300000">$300,000
<OPTION value="350000">$350,000
<OPTION value="400000">$400,000
<OPTION value="450000">$450,000
<OPTION value="500000">$500,000
<OPTION value="600000">$600,000
<OPTION value="700000">$700,000
<OPTION value="750000">$750,000
<OPTION value="800000">$800,000
<OPTION value="900000">$900,000
<OPTION value="1000000">$1,000,000
<OPTION value="1250000">$1,250,000
<OPTION value="1500000">$1,500,000
<OPTION value="1750000">$1,750,000
<OPTION value="2000000">$2,000,000
<OPTION value="2500000">$2,500,000
<OPTION value="3000000">$3,000,000
<OPTION value="5000000">$5,000,000
</SELECT>
</TD>
</TR>
<TR>
<TD> <FONT face="Verdana, Arial, Helvetica, sans-serif" size="2">Premiums
Paid: </FONT> </TD>
<TD>
<INPUT type="radio" checked name="ModeUsed" value="A">
<FONT face="Verdana, Arial, Helvetica, sans-serif" size="2">
Annual<BR>
<INPUT type="radio" name="ModeUsed" value="M">
Monthly </FONT> </TD>
</TR>
</TABLE>
<P>
<INPUT type="submit" name="CqsComparison" value="Press to Instantly Compare 150+ Companies">
</P>
</FORM>
</DIV>
<DIV align="left">
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<FONT face="Arial, Helvetica, sans-serif" size="2" color="#CCCCCC">©</FONT>
<FONT size="1" face="Verdana, Arial, Helvetica, sans-serif" color="#CCCCCC">1999
- 2003 Horenberg Insurance Services, Inc.</FONT></DIV>
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