BRASIL - Information Request Form

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src="images/line.jpg" width="246" height="3"></td> </tr> <tr> </tr> </table> </td> </tr> </table> <p align="center"><font face="Arial, Helvetica, sans-serif"><font size="2">If you would like more information on Special Risks </font></font><font face="Arial" size="2">Insurance, </font><font face="Arial, Helvetica, sans-serif" size="2">p</font><font face="Arial, Helvetica, sans-serif"><font size="2">lease complete the form below</font></font><font face="Arial" size="2">.<br> We will respond to your request as soon as we can.</font></p> <p align="center"><font color="#FFFFFF" face="Arial" size="4"><strong> <input type="hidden" name="VTI-GROUP" value="0"> <font color="#0066CC">P</font><font color="#000000">ersonal <font color="#0066CC">I</font>nformation</font></strong></font></p> <form method="post" action> <font size="2" color="#000000" face="Arial, Helvetica, sans-serif"><strong> <input type="hidden" name="recipient" value="watt@chapter.co.uk"> <input type="hidden" name="sort" value="order:title,full_name,occupation,company,address,city_state,country,post_ZIP_code,phone_number,fax_number,EMail_address,best_time,pm_am,Financial_Institutions_Insurance,Professional_Indemnity_Insurance,Electronic_and_Computer_Crime,Computer_Systems_Coverage,Directors_and_Officers_Insurance,Stockbrokers_Indemnity,Credit_Card_Insurance,Cash_in_Transit_Insurance,Bankers_Blanket_Bond,All_Risks,Construction_All_Risks,Medical_Coverage,Group_Life,Finite_Insurance_Solutions,Safe_Deposit_Box,Liability_Insurance,Kidnap,Mortgage_Impairment,Lenders_Single_Interest,Fine_Art,Employee_Serious_Illness,Group_Personal_Accident,Keyman_Cover,Organ_Transplant,Comments_and_Requirements"> </strong></font> <font size="2" color="#000000" face="Arial, Helvetica, sans-serif"><strong> <input type="hidden" name="redirect" value="http://www.brasil.co.uk/thanks.htm"> </strong></font> <table width="100%" border="0" cellspacing="0" cellpadding="0"> <tr> <td width="75%"> <table width="100%" border="0" cellspacing="0" cellpadding="0"> <tr> <td bgcolor="#FFFFFF" width="30%"> <p><font size="2" color="#000000" face="Arial, Helvetica, sans-serif"><strong>Title: </strong></font></p> </td> <td bgcolor="#FFFFFF"></td> <td bgcolor="#FFFFFF"><font face="Arial" size="2" color="#000000"><font face="Arial Narrow"> <input type="radio" value="Mr" name="title" tabindex="1"> Mr   <input type="radio" value="Mrs" name="title" tabindex="1"> Mrs   <input type="radio" value="Miss" name="title" tabindex="1"> Miss   <input type="radio" value="Ms" name="title" tabindex="1"> Ms   <input type="radio" value="Other" checked name="title" tabindex="1"> Other: </font> <input type="text" name="Other_Title" size="10" tabindex="1"> </font></td> </tr> <tr> <td bgcolor="#FFFFFF" width="30%"><font size="2" color="#000000" face="Arial, Helvetica, sans-serif"><strong>Full Name:</strong></font></td> <td bgcolor="#FFFFFF"></td> <td bgcolor="#FFFFFF"><font face="Arial" size="2" color="#000000"> <input type="text" name="full_name" size="45" tabindex="2"> </font></td> </tr> <tr> <td bgcolor="#FFFFFF" width="30%"><font size="2" color="#000000" face="Arial, Helvetica, sans-serif"><strong>Occupation:</strong></font></td> <td bgcolor="#FFFFFF"></td> <td bgcolor="#FFFFFF"><font face="Arial" size="2" color="#000000"> <input type="text" name="occupation" size="30" tabindex="3"> </font></td> </tr> <tr> <td bgcolor="#FFFFFF" width="30%"><font size="2" color="#000000" face="Arial, Helvetica, sans-serif"><strong>Company:</strong></font></td> <td bgcolor="#FFFFFF"></td> <td bgcolor="#FFFFFF"><font face="Arial" size="2" color="#000000"> <input type="text" name="company" size="30" tabindex="4"> </font></td> </tr> <tr> <td bgcolor="#FFFFFF" width="30%"><font size="2" color="#000000" face="Arial, Helvetica, sans-serif"><strong>Address:</strong></font></td> <td bgcolor="#FFFFFF"></td> <td bgcolor="#FFFFFF"><font face="Arial" size="2" color="#000000"> <input type="text" name="address" size="45" tabindex="5"> </font></td> </tr> <tr> <td bgcolor="#FFFFFF" width="30%"><font size="2" color="#000000" face="Arial, Helvetica, sans-serif"><strong>City/State:</strong></font></td> <td bgcolor="#FFFFFF"></td> <td bgcolor="#FFFFFF"><font face="Arial" size="2" color="#000000"> <input type="text" name="city_state" size="17" tabindex="6"> </font><font size="2" color="#000000" face="Arial, Helvetica, sans-serif"><strong> Country:</strong></font> <font face="Arial" size="2" color="#000000"> <input type="text" name="country" size="17" tabindex="8"> </font></td> </tr> <tr> <td bgcolor="#FFFFFF" width="30%"><font size="2" color="#000000" face="Arial, Helvetica, sans-serif"><strong>Post/ZIP code:</strong></font></td> <td bgcolor="#FFFFFF"></td> <td bgcolor="#FFFFFF"><font face="Arial" size="2" color="#000000"> <input type="text" name="post_ZIP_code" size="15" tabindex="7"> </font></td> </tr> <tr> <td bgcolor="#FFFFFF" width="30%"><font size="2" color="#000000" face="Arial, Helvetica, sans-serif"><strong>Phone Number:</strong></font></td> <td bgcolor="#FFFFFF"></td> <td bgcolor="#FFFFFF"><font face="Arial" size="2" color="#000000"> <input type="text" name="phone_number" size="25" tabindex="9"> </font></td> </tr> <tr> <td bgcolor="#FFFFFF" width="30%"><font size="2" color="#000000" face="Arial, Helvetica, sans-serif"><strong>Fax Number:</strong></font></td> <td bgcolor="#FFFFFF"></td> <td bgcolor="#FFFFFF"><font face="Arial" size="2" color="#000000"> <input type="text" name="fax_number" size="25" tabindex="10"> </font></td> </tr> <tr> <td bgcolor="#FFFFFF" width="30%"><font size="2" color="#000000" face="Arial, Helvetica, sans-serif"><strong>E-Mail Address:</strong></font></td> <td bgcolor="#FFFFFF"></td> <td bgcolor="#FFFFFF"><font face="Arial" size="2" color="#000000"> <input type="text" name="EMail_address" size="25" tabindex="11"> </font></td> </tr> <tr> <td bgcolor="#FFFFFF" width="30%"><font size="2" color="#000000" face="Arial, Helvetica, sans-serif"><strong>Best Time to Contact:</strong></font></td> <td bgcolor="#FFFFFF"></td> <td bgcolor="#FFFFFF"><font face="Arial" size="2" color="#000000"> <input type="text" name="best_time" size="10" tabindex="12"> <input type="radio" value="pm" name="pm_am" tabindex="12"> p.m. <input type="radio" value="am" checked name="pm_am" tabindex="12"> am</font></td> </tr> <tr> <td bgcolor="#FFFFFF" width="30%">  </td> <td bgcolor="#FFFFFF"></td> <td bgcolor="#FFFFFF"></td> </tr> <tr> <td bgcolor="#FFFFFF" colspan="3"> <p align="center"><strong><font face="Arial" size="4" color="#0066CC">I</font><font face="Arial" size="4" color="#000000">nformation <font color="#0066CC">R</font>equired<br> </font></strong><font color="#000000" face="Arial" size="2">Please click on the boxes below to indicate the areas where more information is required.</font> </td> </tr> <tr> <td width="574" bgcolor="#FFFFFF" colspan="3"> </td> </tr> <tr> <td width="574" bgcolor="#FFFFFF" colspan="3"> <p align="center"><font face="Arial" size="3"><strong><font color="#0066CC"><i><font color="#000000">Financial Institutions Insurance</font></i></font> </strong></font> </td> </tr> </table> <table width="100%" border="0" cellspacing="0" cellpadding="0"> <tr bgcolor="#FFFFFF"> <td width="63%" valign="top"> <div align="left"><font color="#000000" face="Arial, Helvetica, sans-serif" size="2"><strong> <input type="checkbox" name="Financial_Institutions_Insurance" value="Financial_Institutions_Insurance" checked tabindex="13"> Financial Institutions Insurance and Reinsurance</strong> </font> </div> <p align="left"><font color="#000000" face="Arial, Helvetica, sans-serif" size="2"><strong> <input type="checkbox" name="Professional_Indemnity_Insurance" value="Professional_Indemnity_Insurance" tabindex="18"> Professional Indemnity Insurance</strong> </font><font color="#000000" size="2" face="Arial, Helvetica, sans-serif"><strong> </strong></font></p> <p align="left"><font color="#000000" size="2" face="Arial, Helvetica, sans-serif"><strong> <input type="checkbox" name="Electronic_and_Computer_Crime" value="Electronic_and_Computer_Crime" tabindex="15"> Electronic and Computer Crime</strong></font></p> <p align="left"><font color="#000000" size="2" face="Arial, Helvetica, sans-serif"><strong> <input type="checkbox" name="Computer_Systems_Coverage" value="Computer_Systems_Coverage" tabindex="16"> Computer Systems Coverage</strong></font></p> <p align="left"><font color="#000000" size="2" face="Arial, Helvetica, sans-serif"><strong> <input type="checkbox" name="Directors_and_Officers_Insurance" value="Directors_and_Officers_Insurance" tabindex="17"> Directors and Officers Insurance</strong></font> </td> <td width="5" valign="top"> <div align="left"><font size="2"></font></div> </td> <td width="37%" valign="top"> <div align="left"><font color="#000000" face="Arial, Helvetica, sans-serif" size="2"><strong> </strong></font> </div> <p align="left"><font color="#000000" size="2" face="Arial, Helvetica, sans-serif"><strong> <input type="checkbox" name="Stockbrokers_Indemnity" value="Stockbrokers_Indemnity" tabindex="19"> Stockbrokers' Indemnity</strong></font></p> <p align="left"><font color="#000000" size="2" face="Arial, Helvetica, sans-serif"><strong> <input type="checkbox" name="Credit_Card_Insurance" value="Credit_Card_Insurance" tabindex="20"> Credit Card Insurance</strong></font></p> <p align="left"><font color="#000000" size="2" face="Arial, Helvetica, sans-serif"><strong> <input type="checkbox" name="Cash_in_Transit_Insurance" value="Cash_in_Transit_Insurance" tabindex="21"> Cash in Transit Insurance</strong></font></p> <p align="left"><font color="#000000" size="2" face="Arial, Helvetica, sans-serif"><strong> <input type="checkbox" name="Bankers_Blanket_Bond" value="Bankers_Blanket_Bond" tabindex="14"> Bankers' Blanket Bond</strong></font> </td> </tr> <tr bgcolor="#FFFFFF"> <td colspan="3"> </td> </tr> <tr bgcolor="#FFFFFF"> <td colspan="3"> <p align="center"><font face="Arial" size="3"><strong><font color="#0066CC"><i><font color="#000000">Other Financial Institutions Products</font></i></font> </strong></font> </td> </tr> <tr bgcolor="#FFFFFF"> <td width="310" valign="top"><font face="Arial, Helvetica, sans-serif"><b><font color="#000000" size="2"><strong> <input type="checkbox" name="All_Risks" value="All_Risks" tabindex="22"> All Risks & Consequential Loss</strong><br> </font> </b> </font> <p><font face="Arial, Helvetica, sans-serif"><b><font color="#000000" size="2"><strong> <input type="checkbox" name="Construction_All_Risks" value="Construction_All_Risks" tabindex="23"> Construction All Risks/Erection All Risks</strong></font></b></font></p> <p><font face="Arial, Helvetica, sans-serif"><b><font color="#000000" size="2"><strong> <input type="checkbox" name="Medical_Coverage" value="Medical_Coverage" tabindex="24"> International/Self Funded Medical Coverage</strong></font></b></font></p> <p><font face="Arial, Helvetica, sans-serif"><b><font color="#000000" size="2"><strong> <input type="checkbox" name="Group_Life" value="Group_Life" tabindex="25"> Death in Services Benefit/Group Life</strong></font></b></font></p> <p><font face="Arial, Helvetica, sans-serif"><b><font color="#000000" size="2"><strong> <input type="checkbox" name="Finite_Insurance_Solutions" value="Finite_Insurance_Solutions" tabindex="26"> Captive/Finite Insurance Solutions</strong></font></b></font></p> <p align="left"><font face="Arial, Helvetica, sans-serif"><b><font color="#000000" size="2"><strong> <input type="checkbox" name="Safe_Deposit_Box" value="Safe_Deposit_Box" tabindex="27"> Safe Deposit Box - All Risks Coverage</strong></font></b></font></p> <p><font face="Arial, Helvetica, sans-serif"><b><font color="#000000" size="2"><strong> <input type="checkbox" name="Liability_Insurance" value="Liability_Insurance" tabindex="28"> Liability Insurance <font size="1">(Third Parties & Employees)</font></strong></font></b></font></p> <p><font face="Arial, Helvetica, sans-serif"><b><font color="#000000" size="2"><strong> <input type="checkbox" name="Kidnap" value="Kidnap" tabindex="29"> Kidnap, Ransom and Extortion</strong></font> </b></font> </td> <td width="13"></td> <td width="211" valign="top"><font face="Arial, Helvetica, sans-serif"><b><font color="#000000" size="2"><strong> <input type="checkbox" name="Mortgage_Impairment" value="Mortgage_Impairment" tabindex="30"> Mortgage Impairment</strong> </font> </b> </font> <p><font face="Arial, Helvetica, sans-serif"><b><font color="#000000" size="2"><strong> <input type="checkbox" name="Lenders_Single_Interest" value="Lenders_Single_Interest" tabindex="31"> Lenders' Single Interest</strong></font></b></font></p> <p><font face="Arial, Helvetica, sans-serif"><b><font color="#000000" size="2"><strong> <input type="checkbox" name="Fine_Art" value="Fine_Art" tabindex="32"> Theft/Fine Art</strong></font></b></font></p> <p><font face="Arial, Helvetica, sans-serif"><b><font color="#000000" size="2"><strong> <input type="checkbox" name="Employee_Serious_Illness" value="Employee_Serious_Illness" tabindex="33"> Employee Serious Illness</strong></font></b></font></p> <p><font face="Arial, Helvetica, sans-serif"><b><font color="#000000" size="2"><strong> <input type="checkbox" name="Group_Personal_Accident" value="Group_Personal_Accident" tabindex="34"> Group Personal Accident</strong></font></b></font></p> <p><font face="Arial, Helvetica, sans-serif"><b><font color="#000000" size="2"><strong> <input type="checkbox" name="Keyman_Cover" value="Keyman_Cover" tabindex="35"> Keyman Cover</strong></font></b></font></p> <p align="left"><font face="Arial, Helvetica, sans-serif"><b><font color="#000000" size="2"><strong> <input type="checkbox" name="Organ_Transplant" value="Organ_Transplant" tabindex="36"> Organ Transplant</strong></font> </b></font> </td> </tr> <tr bgcolor="#FFFFFF"> <td colspan="3">  </td> </tr> <tr bgcolor="#FFFFFF"> <td colspan="3"> <p align="center"><font color="#000000" face="Arial" size="3"><strong><font color="#0066CC">C</font>omments <font color="#0066CC">a</font>nd <font color="#0066CC">R</font>equirements<br> </strong><font size="2">Please add any specific requirements or comments below. </font> </font> </td> </tr> <tr bgcolor="#FFFFFF"> <td colspan="3"> </td> </tr> </table> <div align="center"><font color="#000000"> <textarea name="Comments_and_Requirements" cols="50" tabindex="37" rows="1"></textarea> <br> </font><font face="Arial" size="2">When you have completed the form, press <input type="submit" value="Send" name="B1" style="background-color: rgb(0,70,140); color: rgb(255,255,255); text-transform: none; text-decoration: none"> to submit your request.</font> </div> </td> </tr> </table> </form> <p align="center"> </p> </body>