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<td width="248" height="19"><a href="fii.htm"
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<td width="248" height="19"><img src="images/irf.png" width="227" height="27" alt="Information Request Form"></td>
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<div align="center"><font face="Arial" size="2"><br>
Please complete the form below if you would like more information on World-wide
Travel and Accident Insurance, to discuss a specific requirement or request
a quotation. We will respond to your request as soon as we can.</font>
<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,Travel_and_Accident_Insurance,Tour_Operators_and_Travel_Companies,Travel_Agent,Specialist_Travel,Tour_Operator_Insurance_Package,Financial_Guarantee,Professional_Sports_Insurance,Player,Association,Professional,Amateur,Personal_Accident,Other_Risks,Personal_Accident,Comments_or_Requirements><"0" cellpadding="0" cellspacing="0" width="100%">
<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="10" 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="30" 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%">
<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="100%">
<p><font face="Arial" size="2" color="#000000"><strong>
<input type="checkbox" name="Personal_Accident" value="ON">
Personal Accident and Illness Insurance</strong></font> </p>
<p><font face="Arial" size="2" color="#FFFFFF"><strong><font color="#000000">
<input type="checkbox" name="Travel_and_Accident_Insurance" value="Travel_and_Accident_Insurance" tabindex="13">
World-wide Travel and Accident Insurance</font></strong></font>
</p>
<p><font face="Arial" size="2" color="#000000"><strong>
<input type="checkbox" name="Tour_Operators_and_Travel_Companies" value="Tour_Operators_and_Travel_Companies" tabindex="14">
Travel Insurance For Tour Operators and Travel Companies</strong></font></p>
<table width="100%" border="0" cellspacing="0" cellpadding="0">
<tr>
<td width="10%"> </td>
<td width="40%" valign="top">
<p><font face="Arial" size="2" color="#000000">
<input type="checkbox" name="Travel_Agent" value="Travel_Agent" tabindex="15">
Travel Agent Retail Schemes</font></p>
<p align="left"><font face="Arial" size="2" color="#000000">
<input type="checkbox" name="Specialist_Travel " value="Specialist_Travel " tabindex="16">
Specialist Travel Schemes</font></p>
</td>
<td width="40%" valign="top">
<p align="left"><font face="Arial" size="2" color="#000000">
<input type="checkbox" name="Tour_Operator_Insurance_Package" value="Tour_Operator_Insurance_Package" tabindex="17">
Tour Operator Insurance Package<br>
<br>
</font><font face="Arial" size="2" color="#000000">
<input type="checkbox" name="Financial_Guarantee" value="Financial_Guarantee" tabindex="18">
Financial Guarantee</font></p>
</td>
</tr>
</table>
<p><font face="Arial" size="2" color="#000000"><strong>
<input type="checkbox" name="Professional_Sports_Insurance" value="Professional_Sports_Insurance" tabindex="19">
Professional Sports Insurance</strong></font></p>
<table width="100%" border="0" cellspacing="0" cellpadding="0">
<tr>
<td width="10%"> </td>
<td width="40%" valign="top">
<p><font face="Arial" size="2" color="#000000"><strong> </strong>
<input type="checkbox" name="Player" value="Player" tabindex="20">
As a Player</font></p>
<p align="left"><font face="Arial" size="2" color="#000000">
<input type="checkbox" name="Association" value="Association" tabindex="21">
As an Association</font></p>
<p><font face="Arial" size="2" color="#000000">
<input type="checkbox" name="Professional" value="Professional" tabindex="22">
As a Professional</font></p>
</td>
<td width="40%">
<p><font face="Arial" size="2" color="#000000">
<input type="checkbox" name="Amateur" value="Amateur" tabindex="23">
As an Amateur</font></p>
<p align="left"><font face="Arial" size="2" color="#000000">
<input type="checkbox" name="Personal_Accident2" value="Personal_Accident" tabindex="24">
For Personal Accident</font></p>
<p><font face="Arial" size="2" color="#000000">
<input type="checkbox" name="Other_Risks" value="Other_Risks" tabindex="26">
For Travel/Other Risks</font></p>
</td>
</tr>
</table>
</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%">
<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%">
<div align="center">
<center>
<p><font color="#000000"> <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="27"></textarea>
</font>
</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="B1" style="background-color: rgb(0,70,140); color: rgb(255,255,255)">
to submit your request.</font></p>
<p><font face="Arial" 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> |<br>
</font><font face="Arial" size="1">| <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" target="main">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>
</div>
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