<TABLE border="1" width="468" CELLPADDING="0" CELLSPACING="0" height="58" bgcolor="#CCCCCC"> <INPUT type="hidden" name="sysId" value="CIGI"> <INPUT type="hidden" name="genCount" value="8"> <INPUT type="hidden" name="gen_7" value="FK"> <TR> <FORM METHOD="get" ACTION="http://adfarce.1mgis.com/adcgi|25|10470|1|1|link=http://24.eterm.com/cgi-bin/cigiqtr.exe"> <TD ALIGN=center VALIGN=TOP><TABLE border="0" width="468" CELLPADDING="0" CELLSPACING="0" height="58" bgcolor="#CCCCCC"> <TR><TD ALIGN=center VALIGN=TOP COLSPAN=5> <INPUT TYPE="image" src="//imageserv.imgis.com/apps/Ad56147St3Sz1Sq1Id1/image1bw3.gif" border="0" width=450 height=17 Value="submit"> </TD></TR> <TR align="center" valign="bottom"> <TD align="center" valign="top"> <FONT SIZE="-2" face="Arial,Helvetica" color="#000000">Coverage</FONT><BR> <FONT face="Arial,Helv,Sans-Serif" size="-2"> <SELECT name="gen_6" size="1"> <OPTION value="!">Select</OPTION> <OPTION value="100,000">$100k</OPTION> <OPTION value="150,000">$150k</OPTION> <OPTION value="200,000">$200k</OPTION> <OPTION value="250,000">$250k</OPTION> <OPTION value="300,000">$300k</OPTION> <OPTION value="350,000">$350k</OPTION> <OPTION value="400,000">$400k</OPTION> <OPTION value="450,000">$450k</OPTION> <OPTION value="500,000">$500k</OPTION> <OPTION value="750,000">$750k</OPTION> <OPTION value="1,000,000">$1Mil</OPTION> <OPTION value="1,500,000">$1.5Mil</OPTION> <OPTION value="2,000,000">$2Mil</OPTION> <OPTION value="2,500,000">$2.5Mil</OPTION> <OPTION value="3,000,000">$3Mil</OPTION> <OPTION value="3,500,000">$3.5Mil</OPTION> <OPTION value="4,000,000">$4Mil</OPTION> <OPTION value="4,500,000">$4.5Mil</OPTION> </SELECT></FONT></TD> <TD align="center" valign="top"> <FONT SIZE="-2" face="Arial,Helvetica" color="#000000">State</FONT> <BR> <FONT face="Arial,Helv,Sans-Serif" size="-2"> <SELECT NAME="gen_4" size="1"> <OPTION value="AL">AL </OPTION> <OPTION value="AK">AK </OPTION> <OPTION value="AZ">AZ </OPTION> <OPTION value="AR">AR </OPTION> <OPTION value="CA">CA </OPTION> <OPTION value="CO">CO </OPTION> <OPTION value="CT">CT </OPTION> </SELECT></FONT></TD> <TD align="center" valign="top"> <FONT SIZE="-2" face="Arial,Helvetica" color="#000000">Tobacco Use</FONT> <BR> <FONT face="Arial,Helv,Sans-Serif" size="-2"> <SELECT name="gen_5" size="1"> <OPTION value="!">Select</OPTION> <OPTION value="Never">Never</OPTION> <OPTION value="None In Last 5 Yrs">None 5 Yrs</OPTION> <OPTION value="None In Last 4 Yrs">None 4 Yrs</OPTION> <OPTION value="None In Last 3 Yrs">None 3 Yrs</OPTION> <OPTION value="None In Last 2 Yrs">None 2 Yrs</OPTION> <OPTION value="None In Last Year">None 1 Yr</OPTION> <OPTION value="Used Within Last Year">In Past Yr</OPTION> <OPTION value="Current User">Currently</OPTION> </SELECT></FONT></TD> <TD align="center" valign="top"> <FONT SIZE="-2" face="Arial,Helvetica" color="#000000">Birthdate(mmddyyyy)</FONT> <BR> <FONT face="Arial,Helv,Sans-Serif" size="-2"> <INPUT type="text" name="gen_0" size="2" maxlength="2" value=""> <INPUT type="text" name="gen_1" size="2" maxlength="2" value=""> <INPUT type="text" name="gen_2" size="4" maxlength="4" value=""> </FONT></TD> <TD align="center" valign="top"> <FONT SIZE="-2" color="#000000" FACE="ARIAL,HELVETICA">Gender</FONT> <BR> <FONT face="Arial,Helv,Sans-Serif" size="-2"> <SELECT name="gen_3" size="1"> <OPTION selected value="M">M</OPTION> <OPTION value="F">F</OPTION> </SELECT></FONT></TD></TR></TABLE></TD></FORM></TR> </TABLE>