Special Risks Information Request Form

<body bgcolor="#FFFFFF" link="#0066CC" vlink="#0066CC" alink="#66CBE8"> <table width="100%" border="0" cellspacing="0" cellpadding="0"> <tr> <td width="70%"> <table width="100%" border="0" cellspacing="0" cellpadding="0"> <tr> <td width="248" height="19"><a href="fii.htm" onMouseOver="MM_swapImage('document.Image1','document.Image1','navigation/fB.png','#943360821440');MM_displayStatusMsg('Insurance products for Financial Institutions');return document.MM_returnValue" onMouseOut="MM_swapImgRestore()" target="main"><img src="navigation/fA.png" width="218" height="17" border="0" name="Image1"></a></td> <td width="10" height="19"></td> <td width="139" height="19"><font face="Arial, Helvetica, sans-serif" size="2"><a href="groupinfo.htm" onMouseOut="MM_swapImgRestore()" onMouseOver="MM_swapImage('document.Image6','document.Image6','navigation/gB.png','#943361535200');MM_displayStatusMsg('Information on Group Companies');return document.MM_returnValue" target="main"><img 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onMouseOver="MM_swapImage('document.Image11','document.Image11','navigation/homeB.png','#943448277990');MM_displayStatusMsg('Back to Home Page');return document.MM_returnValue" target="_top"><img src="navigation/homeA.png" width="60" height="17" border="0" name="Image11"></a></td> </tr> <tr valign="middle"> <td width="248" height="19"><img src="images/irf.png" width="227" height="27" alt="Information Request Form"></td> <td width="10" height="19"></td> <td width="234" colspan="3" height="19"><img src="images/line.jpg" width="246" height="3"></td> </tr> </table> </td> </tr> </table> <p align="center"><font face="Arial" size="2">Please complete the form below if you would like more information on Special Risks Insurance, or to discuss a specific requirement or request a quotation. We will respond to your request as soon as we can.</font></p> <form method="post" action=""> <input type=hidden name=recipient value="watt@chapter.co.uk"> <input type=hidden name=redirect value="http://www.brasil.co.uk/thanks.htm"> <input type=hidden name=sort value="order:title,other_title,Full_Name,Occupation,Company,Address,City_State,Post_ZIP_Code,Country,Phone_Number,Fax_Number,EMail_Address,Best_Time,pm_am,Jewellers_Block,Fine_Art,Personal_Jewellery,Life_Assurance,Medical_Assurance,Contingency_Insurance,Hole_in_One,Promotional_Games_Shows,Prize_Indemnity,Comments_or_Requirements"0" cellpadding="0" cellspacing="0" width="100%"> <tr bgcolor="#FFFFFF"> <td width="100%"> <div align="center"> <center> <p><font color="#FFFFFF" face="Arial" size="4"><strong><font color="#0066CC">P</font><font color="#000000">ersonal <font color="#0066CC">I</font>nformation</font></strong></font> </center> </div> </td> </tr> <tr align="center"> <td width="100%"></td> </tr> <div align="center"> <center> <table border="0" cellpadding="0" cellspacing="0" width="100%"> <tr bgcolor="#FFFFFF"> <td width="30%"><font face="Arial" size="2" color="#000000"><strong>Title:</strong></font></td> <td width="70%"><font face="Arial" size="2" color="#000000"> <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><font color="#000000"> <input type="text" name="Other_Title" size="5" tabindex="1"> </font></td> </tr> <tr bgcolor="#FFFFFF"> <td width="30%"><font face="Arial" size="2" color="#000000"><strong>Full Name:</strong></font></td> <td width="70%"><font color="#000000"> <input type="text" name="Full_Name" size="40" tabindex="2"> </font></td> </tr> <tr bgcolor="#FFFFFF"> <td width="30%"><font face="Arial" size="2" color="#000000"><strong>Occupation:</strong></font></td> <td width="70%"><font color="#000000"> <input type="text" name="Occupation" size="30" tabindex="3"> </font></td> </tr> <tr bgcolor="#FFFFFF"> <td width="30%"><font face="Arial" size="2" color="#000000"><strong>Company:</strong></font></td> <td width="70%"><font color="#000000"> <input type="text" name="Company" size="30" tabindex="4"> </font></td> </tr> <tr bgcolor="#FFFFFF"> <td width="30%"><font face="Arial" size="2" color="#000000"><strong>Address:</strong></font></td> <td width="70%"><font color="#000000"> <input type="text" name="Address" size="35" tabindex="5"> </font></td> </tr> <tr bgcolor="#FFFFFF"> <td width="30%"><font face="Arial" size="2" color="#000000"><strong>City/State</strong></font></td> <td width="70%"><font color="#000000"> <input type="text" name="City_State" size="20" tabindex="6"> </font></td> </tr> <tr bgcolor="#FFFFFF"> <td width="30%"><font face="Arial" size="2" color="#000000"><strong>Post/ZIP code:</strong></font></td> <td width="70%"><font color="#000000"> <input type="text" name="Post_ZIP_Code" size="10" tabindex="7"> </font></td> </tr> <tr bgcolor="#FFFFFF"> <td width="30%"><font face="Arial" size="2" color="#000000"><strong>Country:</strong></font></td> <td width="70%"><font color="#000000"> <input type="text" name="Country" size="20" tabindex="8"> </font></td> </tr> <tr bgcolor="#FFFFFF"> <td width="30%"><font face="Arial" size="2" color="#000000"><strong>Phone Number:</strong></font></td> <td width="70%"><font color="#000000"> <input type="text" name="Phone_Number" size="30" tabindex="9"> </font></td> </tr> <tr bgcolor="#FFFFFF"> <td width="30%"><font face="Arial" size="2" color="#000000"><strong>Fax Number:</strong></font></td> <td width="70%"><font color="#000000"> <input type="text" name="Fax_Number" size="30" tabindex="10"> </font></td> </tr> <tr bgcolor="#FFFFFF"> <td width="30%"><font face="Arial" size="2" color="#000000"><strong>E-mail Address:</strong></font></td> <td width="70%"><font color="#000000"> <input type="text" name="EMail_Address" size="30" tabindex="11"> </font></td> </tr> <tr bgcolor="#FFFFFF"> <td width="30%"><font face="Arial" size="2" color="#000000"><strong>Best Time to Contact:</strong></font></td> <td width="70%"><font color="#000000"> <input type="text" name="Best_Time" size="10" tabindex="12"> <font face="Arial" size="2"> <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></font></td> </tr> </table> </center> </div> <div align="center"> <center> <table border="0" cellpadding="0" cellspacing="0" width="100%"> <tr> <td width="100%"></td> </tr> <tr bgcolor="#FFFFFF"> <td width="100%"> </td> </tr> <tr bgcolor="#FFFFFF"> <td width="100%"> <div align="center"> <center> <p><font face="Arial" size="4" color="#000000"><strong><font color="#0066CC">I</font>nformation <font color="#0066CC">R</font>equired</strong></font> </center> </div> </td> </tr> <tr align="center" bgcolor="#FFFFFF"> <td width="100%"> <div align="center"> <center> <p><font face="Arial, Helvetica, sans-serif" size="2">Please click on the boxes below to indicate the areas where you would like more information.</font> </center> </div> </td> </tr> <tr align="center"> <td width="100%"></td> </tr> </table> </center> </div> <div align="center"> <center> <table border="0" cellpadding="0" cellspacing="0" width="100%"> <tr bgcolor="#FFFFFF"> <td width="50%" valign="top"><font color="#000000"><b> <input type="checkbox" name="Jewellers_Block" value="Jewellers_Block" tabindex="13"> <font face="Arial" size="2">Jewellers Block</font></b> </font> <p><font color="#000000"><b><font face="Arial" size="2"> <input type="checkbox" name="Fine_Art" value="Fine_Art" tabindex="14"> Fine Art/Antique</font></b></font></p> <p><font color="#000000"><b><font face="Arial" size="2"> <input type="checkbox" name="Personal_Jewellery" value="Personal_Jewellery" tabindex="15"> Personal Jewellery</font></b></font></p> <p align="left"><font color="#000000"><b><font face="Arial" size="2"> <input type="checkbox" name="Life_Assurance" value="Life_Assurance" tabindex="16"> Life Assurance/Reassurance</font></b></font></p> <p><font color="#000000"><b><font face="Arial" size="2"> <input type="checkbox" name="Medical_Assurance" value="Medical_Assurance" tabindex="17"> Medical Insurance/Reinsurance</font></b> </font> </td> <td width="50%" valign="top"><font face="Arial" size="2" color="#000000"> <input type="checkbox" name="Contingency_Insurance" value="Contingency_Insurance" tabindex="18"> <b>Contingency Insurance</b></font> <p align="left"><font color="#000000"><b><font face="Arial" size="2"> <input type="checkbox" name="Hole_in_One" value="Hole_in_One" tabindex="19"> Hole-in-one</font></b></font></p> <p><font color="#000000"><b><font face="Arial" size="2"> <input type="checkbox" name="Promotional_Games_Shows" value="Promotional_Games_Shows" tabindex="20"> Promotional Games Shows</font></b></font></p> <p><font color="#000000"><b><font face="Arial" size="2"> <input type="checkbox" name="Prize_Indemnity" value="Prize_Indemnity" tabindex="21"> Prize Indemnity</font></b> </font> </td> </tr> </table> </center> </div> <div align="center"> <center> <table border="0" cellpadding="0" cellspacing="0" width="100%"> <tr> <td width="100%"></td> </tr> <tr bgcolor="#FFFFFF"> <td width="100%"> </td> </tr> <tr bgcolor="#FFFFFF"> <td width="100%"> <div align="center"> <center> <p><font face="Arial" size="4" color="#000000"><strong><font color="#0066CC">C</font>omments or <font color="#0066CC">R</font>equirements</strong></font> </center> </div> </td> </tr> <tr align="center" bgcolor="#FFFFFF"> <td width="100%"></td> </tr> <tr align="center" bgcolor="#FFFFFF"> <td width="100%"> <div align="center"> <center> <p> <font face="Arial, Helvetica, sans-serif" size="2">Please add any specific requirements or comments below.</font><br> <textarea rows="2" name="Comments_or_Requirements" cols="50" tabindex="22"></textarea> </center> </div> </td> </tr> </table> </center> </div> <div align="center"> <center> <p><font face="Arial" size="2">When you have completed the form, press <input type="submit" value="Send" name="Submit" style="background-color: rgb(0,70,140); color: rgb(255,255,255)"> to send your request to us.</font></p> <p><font face="Arial, Helvetica, sans-serif" size="1">| <a href="fii.htm" style="text-decoration: none" target="main">Financial Institutions Insurance</a> | <a href="srisk.htm" style="text-decoration: none" target="main">Special Risks Insurance</a> | <a href="trvl.htm" style="text-decoration: none" target="main">Travel, Accident & Health Insurance</a><a href="wordlib.htm" style="text-decoration: none" target="main"> </a>| <br> <a href="trvl.htm" style="text-decoration: none" target="main"></a> | <a href="proplibframe.htm" style="text-decoration: none" target="_top">Proposal Library </a>|<a href="wordlib.htm" style="text-decoration: none" target="main"> Wording Library </a>| <a href="contact.htm" style="text-decoration: none" target="main">Contact Us</a> | <a href="groupinfo.htm" style="text-decoration: none" target="main">Group Information</a> | <a href="linksframe.htm" style="text-decoration: none" target="_top">Useful Links</a> | <a href="history.htm" style="text-decoration: none">History</a> | <a href="map.htm" style="text-decoration: none" target="main">Site Map</a> | <a href="index.htm" style="text-decoration: none" target="_top">Home</a> | </font></p> </center> </div> </form> </body>