ÿþ<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN"> <html><head> <!-- CHANGE THE NEXT THREE LINES --> <title>Form-Policy Review</title> <META name="description" content="Use our easy to use web based policy review form to see if we can offer you a better policy Fill it out today and fax us a copy of your current policy! After we receive your information, we will review your policy line by line and determine if we can offer you a better policy"> <META name="keywords" content="Policy review form, policy review, free,easy to use, fast and accurate,Fill it out Today"> <!-- CHANGE THE ABOVE THREE LINES --> <META http-equiv="Content-Type" content="text/html; charset=iso-8859-1"> <META name="Publisher" content="Allwebco Webpage Design http://allwebcodesign.com/"> <link rel="StyleSheet" href="coolstyle.css" type="text/css"> <script language="JavaScript" type="text/javascript" src="javascripts.js"></script> <script language="JavaScript" type="text/javascript" src="pop-closeup.js"></script> </head> <BODY BGCOLOR="#6F8C8F" TEXT="#FFFFFF" leftmargin="0" rightmargin="0" topmargin="0" bottommargin="0" marginheight="0" marginwidth="0"> <!-- OUTER TABLE--> <TABLE cellpadding="0" cellspacing="0" border="0" width="100%" height="100%"><tr><td valign="top"> <!-- SPLIT TABLE--> <TABLE cellpadding="0" cellspacing="0" border="0" width="100%" bgcolor="#6F8C8F"><tr><td align="left" valign="top"> <script language="JavaScript" type="text/javascript" src="header.js"></script> <br> <CENTER> <!-- MAIN TABLE--> <TABLE cellpadding="0" cellspacing="10" border="0" width="586"> <tr><td align="left" valign="top"> <hr class="page-splits"> <br> <span class="title"><font face="Verdana" color="#F0F0F0">POLICY REVIEW<font color="#F0F0F0"> </font> </font><br></span><font face="Arial"> We appreciate the opportunity to review your current or recently expired insurance policy. Privacy is your right and our concern.</font><font face="Verdana">&nbsp;</font><font size="2">Are you getting the lowest rate? Do you have the proper coverage? Are you with the correct company for you ? We can answer these questions for you by reviewing your policy. This service is free.&nbsp; All you will need to do is fax us (631-476-1378) a copy of your current declaration page and fill out a policy review form. After&nbsp; we receive your information, we will review your policy line by line and determine if we can offer you a better policy.</font><p>&nbsp;</p> <div align="center"> <table border="0" width="247" style="border-collapse: collapse" id="table21"> <tr> <td> <div align="center"> <table border="0" width="309" style="border-collapse: collapse" id="table22"> <tr> <td> <p align="center"><font color="#F0F0F0" size="3"><b>Policy Review&nbsp; -&nbsp;&nbsp; We Make it Easy !</b></font></td> </tr> <tr> <td> <ul> <li>Please Fax us your Declaration page - This page shows your coverage and price paid.</li> <li>Please Fill in form below and submit form</li> <li>We will get back to you in a timely manner!</li> </ul> </td> </tr> </table> </div> </td> </tr> </table> </div> <p>&nbsp;</p> <p> <br> </p> <center> <!-- QUOTE FORM TABLE --> <TABLE cellpadding="0" cellspacing="15" border="1" background="picts/background-quotes.jpg" width="573" style="border-collapse: collapse" bordercolordark="#000000" bordercolorlight="#CCFFFF"><tr><td> <!-- TO REMOVE FORM DELETE TEXT BETWEEN THESE COMMENTS --> <!--webbot BOT="GeneratedScript" PREVIEW=" " startspan --><script Language="JavaScript" Type="text/javascript"><!-- function FrontPage_Form1_Validator(theForm) { if (theForm.Last_Name.value == "") { alert("Please enter a value for the \"Last_Name\" field."); theForm.Last_Name.focus(); return (false); } if (theForm.First_Name.value == "") { alert("Please enter a value for the \"First_Name\" field."); theForm.First_Name.focus(); return (false); } if (theForm.Street_Address.value == "") { alert("Please enter a value for the \"Street_Address\" field."); theForm.Street_Address.focus(); return (false); } if (theForm.City.value == "") { alert("Please enter a value for the \"City\" field."); theForm.City.focus(); return (false); } if (theForm.State.value == "") { alert("Please enter a value for the \"State\" field."); theForm.State.focus(); return (false); } var checkOK = "ABCDEFGHIJKLMNOPQRSTUVWXYZabcdefghijklmnopqrstuvwxyz’`R}aS~xÀÁÂÃÄÅÆÇÈÉÊËÌÍÎÏÐÑÒÓÔÕÖØÙÚÛÜÝÞßàáâãäåæçèéêëìíîïðñòóôõöøùúûüýþÿ \t\r\n\f"; var checkStr = theForm.State.value; var allValid = true; var validGroups = true; for (i = 0; i < checkStr.length; i++) { ch = checkStr.charAt(i); for (j = 0; j < checkOK.length; j++) if (ch == checkOK.charAt(j)) break; if (j == checkOK.length) { allValid = false; break; } } if (!allValid) { alert("Please enter only letter and whitespace characters in the \"State\" field."); theForm.State.focus(); return (false); } var chkVal = theForm.State.value; var prsVal = chkVal; if (chkVal != "" && !(prsVal == "New York")) { alert("Please enter a value equal to \"New York\" in the \"State\" field."); theForm.State.focus(); return (false); } if (theForm.Zip_Code.value == "") { alert("Please enter a value for the \"Zip_Code\" field."); theForm.Zip_Code.focus(); return (false); } if (theForm.Zip_Code.value.length < 5) { alert("Please enter at least 5 characters in the \"Zip_Code\" field."); theForm.Zip_Code.focus(); return (false); } if (theForm.Zip_Code.value.length > 5) { alert("Please enter at most 5 characters in the \"Zip_Code\" field."); theForm.Zip_Code.focus(); return (false); } var checkOK = "0123456789-"; var checkStr = theForm.Zip_Code.value; var allValid = true; var validGroups = true; var decPoints = 0; var allNum = ""; for (i = 0; i < checkStr.length; i++) { ch = checkStr.charAt(i); for (j = 0; j < checkOK.length; j++) if (ch == checkOK.charAt(j)) break; if (j == checkOK.length) { allValid = false; break; } allNum += ch; } if (!allValid) { alert("Please enter only digit characters in the \"Zip_Code\" field."); theForm.Zip_Code.focus(); return (false); } if (theForm.DOB.value == "") { alert("Please enter a value for the \"DOB\" field."); theForm.DOB.focus(); return (false); } if (theForm.DOB.value.length < 6) { alert("Please enter at least 6 characters in the \"DOB\" field."); theForm.DOB.focus(); return (false); } if (theForm.DOB.value.length > 8) { alert("Please enter at most 8 characters in the \"DOB\" field."); theForm.DOB.focus(); return (false); } var checkOK = "0123456789-/"; var checkStr = theForm.DOB.value; var allValid = true; var validGroups = true; for (i = 0; i < checkStr.length; i++) { ch = checkStr.charAt(i); for (j = 0; j < checkOK.length; j++) if (ch == checkOK.charAt(j)) break; if (j == checkOK.length) { allValid = false; break; } } if (!allValid) { alert("Please enter only digit and \"/\" characters in the \"DOB\" field."); theForm.DOB.focus(); return (false); } if (theForm.Social_Securitu.value == "") { alert("Please enter a value for the \"Social_Securitu\" field."); theForm.Social_Securitu.focus(); return (false); } if (theForm.Social_Securitu.value.length > 12) { alert("Please enter at most 12 characters in the \"Social_Securitu\" field."); theForm.Social_Securitu.focus(); return (false); } var checkOK = "0123456789-"; var checkStr = theForm.Social_Securitu.value; var allValid = true; var validGroups = true; var decPoints = 0; var allNum = ""; for (i = 0; i < checkStr.length; i++) { ch = checkStr.charAt(i); for (j = 0; j < checkOK.length; j++) if (ch == checkOK.charAt(j)) break; if (j == checkOK.length) { allValid = false; break; } allNum += ch; } if (!allValid) { alert("Please enter only digit characters in the \"Social_Securitu\" field."); theForm.Social_Securitu.focus(); return (false); } if (theForm.Driver_License.value == "") { alert("Please enter a value for the \"Driver_License\" field."); theForm.Driver_License.focus(); return (false); } var checkOK = "0123456789-"; var checkStr = theForm.Driver_License.value; var allValid = true; var validGroups = true; var decPoints = 0; var allNum = ""; for (i = 0; i < checkStr.length; i++) { ch = checkStr.charAt(i); for (j = 0; j < checkOK.length; j++) if (ch == checkOK.charAt(j)) break; if (j == checkOK.length) { allValid = false; break; } allNum += ch; } if (!allValid) { alert("Please enter only digit characters in the \"Driver_License\" field."); theForm.Driver_License.focus(); return (false); } if (theForm.Phone.value == "") { alert("Please enter a value for the \"Phone\" field."); theForm.Phone.focus(); return (false); } var checkOK = "0123456789-()- \t\r\n\f"; var checkStr = theForm.Phone.value; var allValid = true; var validGroups = true; for (i = 0; i < checkStr.length; i++) { ch = checkStr.charAt(i); for (j = 0; j < checkOK.length; j++) if (ch == checkOK.charAt(j)) break; if (j == checkOK.length) { allValid = false; break; } } if (!allValid) { alert("Please enter only digit, whitespace and \"()-\" characters in the \"Phone\" field."); theForm.Phone.focus(); return (false); } if (theForm.Fax.value == "") { alert("Please enter a value for the \"Fax\" field."); theForm.Fax.focus(); return (false); } var checkOK = "0123456789-()- \t\r\n\f"; var checkStr = theForm.Fax.value; var allValid = true; var validGroups = true; for (i = 0; i < checkStr.length; i++) { ch = checkStr.charAt(i); for (j = 0; j < checkOK.length; j++) if (ch == checkOK.charAt(j)) break; if (j == checkOK.length) { allValid = false; break; } } if (!allValid) { alert("Please enter only digit, whitespace and \"()-\" characters in the \"Fax\" field."); theForm.Fax.focus(); return (false); } if (theForm.Email.value == "") { alert("Please enter a value for the \"Email\" field."); theForm.Email.focus(); return (false); } var checkOK = "ABCDEFGHIJKLMNOPQRSTUVWXYZabcdefghijklmnopqrstuvwxyz’`R}aS~xÀÁÂÃÄÅÆÇÈÉÊËÌÍÎÏÐÑÒÓÔÕÖØÙÚÛÜÝÞßàáâãäåæçèéêëìíîïðñòóôõöøùúûüýþÿ0123456789-@.-_"; var checkStr = theForm.Email.value; var allValid = true; var validGroups = true; for (i = 0; i < checkStr.length; i++) { ch = checkStr.charAt(i); for (j = 0; j < checkOK.length; j++) if (ch == checkOK.charAt(j)) break; if (j == checkOK.length) { allValid = false; break; } } if (!allValid) { alert("Please enter only letter, digit and \"@.-_\" characters in the \"Email\" field."); theForm.Email.focus(); return (false); } if (theForm.Motorcycle_Info.selectedIndex < 0) { alert("Please select one of the \"Motorcycle_Info\" options."); theForm.Motorcycle_Info.focus(); return (false); } if (theForm.Motorcycle_Info.selectedIndex == 0) { alert("The first \"Motorcycle_Info\" option is not a valid selection. Please choose one of the other options."); theForm.Motorcycle_Info.focus(); return (false); } if (theForm.Year_Unit_1.value == "") { alert("Please enter a value for the \"Year_Unit_1\" field."); theForm.Year_Unit_1.focus(); return (false); } if (theForm.Year_Unit_1.value.length < 4) { alert("Please enter at least 4 characters in the \"Year_Unit_1\" field."); theForm.Year_Unit_1.focus(); return (false); } if (theForm.Year_Unit_1.value.length > 4) { alert("Please enter at most 4 characters in the \"Year_Unit_1\" field."); theForm.Year_Unit_1.focus(); return (false); } var checkOK = "0123456789-"; var checkStr = theForm.Year_Unit_1.value; var allValid = true; var validGroups = true; var decPoints = 0; var allNum = ""; for (i = 0; i < checkStr.length; i++) { ch = checkStr.charAt(i); for (j = 0; j < checkOK.length; j++) if (ch == checkOK.charAt(j)) break; if (j == checkOK.length) { allValid = false; break; } allNum += ch; } if (!allValid) { alert("Please enter only digit characters in the \"Year_Unit_1\" field."); theForm.Year_Unit_1.focus(); return (false); } var chkVal = allNum; var prsVal = parseInt(allNum); if (chkVal != "" && !(prsVal >= "1903" && prsVal <= "2012")) { alert("Please enter a value greater than or equal to \"1903\" and less than or equal to \"2012\" in the \"Year_Unit_1\" field."); theForm.Year_Unit_1.focus(); return (false); } if (theForm.Year_Unit_2.value.length > 4) { alert("Please enter at most 4 characters in the \"Year_Unit_2\" field."); theForm.Year_Unit_2.focus(); return (false); } var checkOK = "0123456789-"; var checkStr = theForm.Year_Unit_2.value; var allValid = true; var validGroups = true; var decPoints = 0; var allNum = ""; for (i = 0; i < checkStr.length; i++) { ch = checkStr.charAt(i); for (j = 0; j < checkOK.length; j++) if (ch == checkOK.charAt(j)) break; if (j == checkOK.length) { allValid = false; break; } allNum += ch; } if (!allValid) { alert("Please enter only digit characters in the \"Year_Unit_2\" field."); theForm.Year_Unit_2.focus(); return (false); } var chkVal = allNum; var prsVal = parseInt(allNum); if (chkVal != "" && !(prsVal >= "1903" && prsVal <= "2012")) { alert("Please enter a value greater than or equal to \"1903\" and less than or equal to \"2012\" in the \"Year_Unit_2\" field."); theForm.Year_Unit_2.focus(); return (false); } if (theForm.Model_Unit_1.value == "") { alert("Please enter a value for the \"Model_Unit_1\" field."); theForm.Model_Unit_1.focus(); return (false); } var checkOK = "ABCDEFGHIJKLMNOPQRSTUVWXYZabcdefghijklmnopqrstuvwxyz’`R}aS~xÀÁÂÃÄÅÆÇÈÉÊËÌÍÎÏÐÑÒÓÔÕÖØÙÚÛÜÝÞßàáâãäåæçèéêëìíîïðñòóôõöøùúûüýþÿ0123456789--/ \t\r\n\f"; var checkStr = theForm.Model_Unit_1.value; var allValid = true; var validGroups = true; for (i = 0; i < checkStr.length; i++) { ch = checkStr.charAt(i); for (j = 0; j < checkOK.length; j++) if (ch == checkOK.charAt(j)) break; if (j == checkOK.length) { allValid = false; break; } } if (!allValid) { alert("Please enter only letter, digit, whitespace and \"-/\" characters in the \"Model_Unit_1\" field."); theForm.Model_Unit_1.focus(); return (false); } var checkOK = "ABCDEFGHIJKLMNOPQRSTUVWXYZabcdefghijklmnopqrstuvwxyz’`R}aS~xÀÁÂÃÄÅÆÇÈÉÊËÌÍÎÏÐÑÒÓÔÕÖØÙÚÛÜÝÞßàáâãäåæçèéêëìíîïðñòóôõöøùúûüýþÿ0123456789--/ \t\r\n\f"; var checkStr = theForm.Model_Unit_2.value; var allValid = true; var validGroups = true; for (i = 0; i < checkStr.length; i++) { ch = checkStr.charAt(i); for (j = 0; j < checkOK.length; j++) if (ch == checkOK.charAt(j)) break; if (j == checkOK.length) { allValid = false; break; } } if (!allValid) { alert("Please enter only letter, digit, whitespace and \"-/\" characters in the \"Model_Unit_2\" field."); theForm.Model_Unit_2.focus(); return (false); } if (theForm.CC_Unit_1.value == "") { alert("Please enter a value for the \"CC_Unit_1\" field."); theForm.CC_Unit_1.focus(); return (false); } if (theForm.CC_Unit_1.value.length < 2) { alert("Please enter at least 2 characters in the \"CC_Unit_1\" field."); theForm.CC_Unit_1.focus(); return (false); } if (theForm.CC_Unit_1.value.length > 4) { alert("Please enter at most 4 characters in the \"CC_Unit_1\" field."); theForm.CC_Unit_1.focus(); return (false); } var checkOK = "0123456789-"; var checkStr = theForm.CC_Unit_1.value; var allValid = true; var validGroups = true; var decPoints = 0; var allNum = ""; for (i = 0; i < checkStr.length; i++) { ch = checkStr.charAt(i); for (j = 0; j < checkOK.length; j++) if (ch == checkOK.charAt(j)) break; if (j == checkOK.length) { allValid = false; break; } allNum += ch; } if (!allValid) { alert("Please enter only digit characters in the \"CC_Unit_1\" field."); theForm.CC_Unit_1.focus(); return (false); } var chkVal = allNum; var prsVal = parseInt(allNum); if (chkVal != "" && !(prsVal >= "50" && prsVal <= "2500")) { alert("Please enter a value greater than or equal to \"50\" and less than or equal to \"2500\" in the \"CC_Unit_1\" field."); theForm.CC_Unit_1.focus(); return (false); } if (theForm.CC_Unit_2.value.length > 4) { alert("Please enter at most 4 characters in the \"CC_Unit_2\" field."); theForm.CC_Unit_2.focus(); return (false); } var checkOK = "0123456789-"; var checkStr = theForm.CC_Unit_2.value; var allValid = true; var validGroups = true; var decPoints = 0; var allNum = ""; for (i = 0; i < checkStr.length; i++) { ch = checkStr.charAt(i); for (j = 0; j < checkOK.length; j++) if (ch == checkOK.charAt(j)) break; if (j == checkOK.length) { allValid = false; break; } allNum += ch; } if (!allValid) { alert("Please enter only digit characters in the \"CC_Unit_2\" field."); theForm.CC_Unit_2.focus(); return (false); } var chkVal = allNum; var prsVal = parseInt(allNum); if (chkVal != "" && !(prsVal >= "50" && prsVal <= "2500")) { alert("Please enter a value greater than or equal to \"50\" and less than or equal to \"2500\" in the \"CC_Unit_2\" field."); theForm.CC_Unit_2.focus(); return (false); } if (theForm.VIN_Unit_1.value == "") { alert("Please enter a value for the \"VIN_Unit_1\" field."); theForm.VIN_Unit_1.focus(); return (false); } if (theForm.VIN_Unit_1.value.length > 17) { alert("Please enter at most 17 characters in the \"VIN_Unit_1\" field."); theForm.VIN_Unit_1.focus(); return (false); } var checkOK = "ABCDEFGHIJKLMNOPQRSTUVWXYZabcdefghijklmnopqrstuvwxyz’`R}aS~xÀÁÂÃÄÅÆÇÈÉÊËÌÍÎÏÐÑÒÓÔÕÖØÙÚÛÜÝÞßàáâãäåæçèéêëìíîïðñòóôõöøùúûüýþÿ0123456789-"; var checkStr = theForm.VIN_Unit_1.value; var allValid = true; var validGroups = true; for (i = 0; i < checkStr.length; i++) { ch = checkStr.charAt(i); for (j = 0; j < checkOK.length; j++) if (ch == checkOK.charAt(j)) break; if (j == checkOK.length) { allValid = false; break; } } if (!allValid) { alert("Please enter only letter and digit characters in the \"VIN_Unit_1\" field."); theForm.VIN_Unit_1.focus(); return (false); } if (theForm.VIN_Unit_2.value.length > 17) { alert("Please enter at most 17 characters in the \"VIN_Unit_2\" field."); theForm.VIN_Unit_2.focus(); return (false); } var checkOK = "ABCDEFGHIJKLMNOPQRSTUVWXYZabcdefghijklmnopqrstuvwxyz’`R}aS~xÀÁÂÃÄÅÆÇÈÉÊËÌÍÎÏÐÑÒÓÔÕÖØÙÚÛÜÝÞßàáâãäåæçèéêëìíîïðñòóôõöøùúûüýþÿ0123456789-"; var checkStr = theForm.VIN_Unit_2.value; var allValid = true; var validGroups = true; for (i = 0; i < checkStr.length; i++) { ch = checkStr.charAt(i); for (j = 0; j < checkOK.length; j++) if (ch == checkOK.charAt(j)) break; if (j == checkOK.length) { allValid = false; break; } } if (!allValid) { alert("Please enter only letter and digit characters in the \"VIN_Unit_2\" field."); theForm.VIN_Unit_2.focus(); return (false); } if (theForm.Type_Of_Policy.selectedIndex < 0) { alert("Please select one of the \"Type_Of_Policy\" options."); theForm.Type_Of_Policy.focus(); return (false); } if (theForm.Type_Of_Policy.selectedIndex == 0) { alert("The first \"Type_Of_Policy\" option is not a valid selection. Please choose one of the other options."); theForm.Type_Of_Policy.focus(); return (false); } if (theForm.Coverage.selectedIndex < 0) { alert("Please select one of the \"Coverage\" options."); theForm.Coverage.focus(); return (false); } if (theForm.Coverage.selectedIndex == 0) { alert("The first \"Coverage\" option is not a valid selection. Please choose one of the other options."); theForm.Coverage.focus(); return (false); } if (theForm.Deductible.selectedIndex < 0) { alert("Please select one of the \"Deductible\" options."); theForm.Deductible.focus(); return (false); } if (theForm.Deductible.selectedIndex == 0) { alert("The first \"Deductible\" option is not a valid selection. Please choose one of the other options."); theForm.Deductible.focus(); return (false); } if (theForm.Spousal_Coverage.selectedIndex < 0) { alert("Please select one of the \"Spousal_Coverage\" options."); theForm.Spousal_Coverage.focus(); return (false); } if (theForm.Spousal_Coverage.selectedIndex == 0) { alert("The first \"Spousal_Coverage\" option is not a valid selection. Please choose one of the other options."); theForm.Spousal_Coverage.focus(); return (false); } if (theForm.OBEL.selectedIndex < 0) { alert("Please select one of the \"OBEL\" options."); theForm.OBEL.focus(); return (false); } if (theForm.OBEL.selectedIndex == 0) { alert("The first \"OBEL\" option is not a valid selection. Please choose one of the other options."); theForm.OBEL.focus(); return (false); } if (theForm.Medical_Payments.selectedIndex < 0) { alert("Please select one of the \"Medical_Payments\" options."); theForm.Medical_Payments.focus(); return (false); } if (theForm.Medical_Payments.selectedIndex == 0) { alert("The first \"Medical_Payments\" option is not a valid selection. Please choose one of the other options."); theForm.Medical_Payments.focus(); return (false); } if (theForm.Roadside.selectedIndex < 0) { alert("Please select one of the \"Roadside\" options."); theForm.Roadside.focus(); return (false); } if (theForm.Roadside.selectedIndex == 0) { alert("The first \"Roadside\" option is not a valid selection. Please choose one of the other options."); theForm.Roadside.focus(); return (false); } if (theForm.Towing.selectedIndex < 0) { alert("Please select one of the \"Towing\" options."); theForm.Towing.focus(); return (false); } if (theForm.Towing.selectedIndex == 0) { alert("The first \"Towing\" option is not a valid selection. Please choose one of the other options."); theForm.Towing.focus(); return (false); } if (theForm.Marital_Status.selectedIndex < 0) { alert("Please select one of the \"Marital_Status\" options."); theForm.Marital_Status.focus(); return (false); } if (theForm.Marital_Status.selectedIndex == 0) { alert("The first \"Marital_Status\" option is not a valid selection. Please choose one of the other options."); theForm.Marital_Status.focus(); return (false); } if (theForm.License.selectedIndex < 0) { alert("Please select one of the \"License\" options."); theForm.License.focus(); return (false); } if (theForm.License.selectedIndex == 0) { alert("The first \"License\" option is not a valid selection. Please choose one of the other options."); theForm.License.focus(); return (false); } if (theForm.MC_Experience.selectedIndex < 0) { alert("Please select one of the \"MC_Experience\" options."); theForm.MC_Experience.focus(); return (false); } if (theForm.MC_Experience.selectedIndex == 0) { alert("The first \"MC_Experience\" option is not a valid selection. Please choose one of the other options."); theForm.MC_Experience.focus(); return (false); } if (theForm.Garage.selectedIndex < 0) { alert("Please select one of the \"Garage\" options."); theForm.Garage.focus(); return (false); } if (theForm.Garage.selectedIndex == 0) { alert("The first \"Garage\" option is not a valid selection. Please choose one of the other options."); theForm.Garage.focus(); return (false); } if (theForm.Violations.selectedIndex < 0) { alert("Please select one of the \"Violations\" options."); theForm.Violations.focus(); return (false); } if (theForm.Violations.selectedIndex == 0) { alert("The first \"Violations\" option is not a valid selection. Please choose one of the other options."); theForm.Violations.focus(); return (false); } if (theForm.Saftey_Certificate.selectedIndex < 0) { alert("Please select one of the \"Saftey_Certificate\" options."); theForm.Saftey_Certificate.focus(); return (false); } if (theForm.Saftey_Certificate.selectedIndex == 0) { alert("The first \"Saftey_Certificate\" option is not a valid selection. Please choose one of the other options."); theForm.Saftey_Certificate.focus(); return (false); } if (theForm.Rider_Group.selectedIndex < 0) { alert("Please select one of the \"Rider_Group\" options."); theForm.Rider_Group.focus(); return (false); } if (theForm.Rider_Group.selectedIndex == 0) { alert("The first \"Rider_Group\" option is not a valid selection. Please choose one of the other options."); theForm.Rider_Group.focus(); return (false); } if (theForm.HomeOwner.selectedIndex < 0) { alert("Please select one of the \"HomeOwner\" options."); theForm.HomeOwner.focus(); return (false); } if (theForm.HomeOwner.selectedIndex == 0) { alert("The first \"HomeOwner\" option is not a valid selection. Please choose one of the other options."); theForm.HomeOwner.focus(); return (false); } if (theForm.Lien_Holder.selectedIndex < 0) { alert("Please select one of the \"Lien_Holder\" options."); theForm.Lien_Holder.focus(); return (false); } if (theForm.Lien_Holder.selectedIndex == 0) { alert("The first \"Lien_Holder\" option is not a valid selection. Please choose one of the other options."); theForm.Lien_Holder.focus(); return (false); } return (true); } //--></script><!--webbot BOT="GeneratedScript" endspan --><form method="POST" action="http://ryde.webhost4life.com/_vti_bin/shtml.dll/Insurance/PolicyReviewform.htm" target="_top" onsubmit="return FrontPage_Form1_Validator(this)" language="JavaScript" name="FrontPage_Form1" webbot-action="--WEBBOT-SELF--"> <!--webbot bot="SaveResults" S-Email-Format="TEXT/PRE" S-Email-Address="rydemc@aol.com" B-Email-Label-Fields="TRUE" B-Email-Subject-From-Field="TRUE" S-Email-Subject="Web Insurance Quote - " S-Date-Format="%m/%d/%Y" S-Time-Format="%I:%M %p" S-Builtin-Fields="REMOTE_NAME REMOTE_USER HTTP_USER_AGENT Date Time" U-Confirmation-Url="thanks.htm" startspan U-Validation-Error-Url="policy_review_sorry.htm" --><input TYPE="hidden" NAME="VTI-GROUP" VALUE="0"><!--webbot bot="SaveResults" endspan i-checksum="43374" --><input type="hidden" name="recipient" VALUE="info@your-web-domain.com"> <input type="hidden" name="subject" VALUE="WebSite Contact"> <input type="hidden" name="redirect" VALUE="http://your-web-domain.com/thanks.htm"> <input type="hidden" name="required" VALUE="email,your_name"> <input type="hidden" name="sort" value="through,your_name,phone,fax,email,comments,company,address,city,state,zip,description1,description2,select1,select2,check1,check2,check3,dropdown1"> <!-- IMPORTANT: IF YOU ADD MORE OPTION FIELDS BE SURE TO ADD THEM TO THE LINE JUST ABOVE THIS NOTE --> <!-- CONTACT TABLE 1 --> <TABLE BORDER="0" cellpadding="2" cellspacing="0" width="525"> <tr><td align="right"> <p align="left"><font color="#F0F0F0" face="Arial"><b>Web Form: Policy Review- </b></font> <span style="font-weight: 400">For an accurate quote, please fill in all fields of this six (5) part form. You can easily navigate this form using the Tab key.</span></p> <div align="center"> <TABLE border="0" id="table1" width="390" cellspacing="5"> <TR> <TD ALIGN="right" nowrap colspan="2" class="title"> <p align="center"><font size="4" face="Verdana">#1-Insured's Information</font></p> <p align="center">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;</TD> </TR> <TR> <TD ALIGN="right" nowrap> <p align="right"><font face="Verdana">Last Name<font color="#0000FF">&nbsp;</font></font></TD> <TD> &nbsp;<!--webbot bot="Validation" s-data-type="String" b-value-required="TRUE" --><INPUT NAME="Last_Name" SIZE="25" CLASS="quoteform" tabindex="1"><font face="Verdana"> </font> </TD> </TR> <TR> <TD ALIGN="right" nowrap> <p><font face="Verdana">First Name&nbsp;&nbsp; </font></TD> <TD> <font face="Verdana"> &nbsp;<!--webbot bot="Validation" s-data-type="String" b-value-required="TRUE" --><input NAME="First_Name" SIZE="25" tabindex="2" class="quoteform"> </font> </TD> </TR> <TR> <TD ALIGN="right" nowrap> <p>Middle Initial&nbsp;&nbsp; </TD> <TD> <font face="Verdana"> &nbsp;<INPUT NAME="Middle_Initial" SIZE=25 tabindex="3" class="quoteform"> </font> </TD> </TR> <TR> <TD ALIGN="right" nowrap> <p><font face="Verdana">Street Address&nbsp;</font></TD> <TD nowrap> <font face="Verdana"> &nbsp;<!--webbot bot="Validation" s-data-type="String" b-value-required="TRUE" --><input NAME="Street_Address" SIZE="25" tabindex="4" class="quoteform">&nbsp; </font> </TD> </TR> <TR> <TD ALIGN="right" nowrap> <p><font face="Verdana">City or Town&nbsp;&nbsp; </font></TD> <TD> <font face="Verdana"> &nbsp;<!--webbot bot="Validation" s-data-type="String" b-value-required="TRUE" --><input NAME="City" SIZE="25" tabindex="5" class="quoteform"> </font> </TD> </TR> <TR> <TD ALIGN="right" nowrap> <p><font face="Verdana">State&nbsp;&nbsp; </font></TD> <TD> <font face="Verdana"> &nbsp;<!--webbot bot="Validation" s-data-type="String" b-allow-letters="TRUE" b-allow-whitespace="TRUE" b-value-required="TRUE" s-validation-constraint="Equal to" s-validation-value="New York" --><input type="text" name="State" size="25" value="New York" class="quoteform"></font></TD> </TR> <TR> <TD ALIGN="right" nowrap> <font face="Verdana">Zip Code&nbsp;&nbsp; </font></TD> <TD> <font face="Verdana"> &nbsp;<!--webbot bot="Validation" s-data-type="Integer" s-number-separators="x" b-value-required="TRUE" i-minimum-length="5" i-maximum-length="5" --><input NAME="Zip_Code" SIZE="25" tabindex="6" class="quoteform" maxlength="5"> </font> </TD> </TR> </center> <tr> <TD ALIGN="right" nowrap> <font face="Verdana">Date of Birth&nbsp;&nbsp; </font></TD> <TD> <font face="Verdana"> &nbsp;<!--webbot bot="Validation" s-data-type="String" b-allow-digits="TRUE" s-allow-other-chars="/" b-value-required="TRUE" i-minimum-length="6" i-maximum-length="8" --><input NAME="DOB" SIZE="25" tabindex="7" class="quoteform" maxlength="8">&nbsp;&nbsp;&nbsp; </font> </TD> </tr> <center> <TR> <TD ALIGN="right" nowrap> <font face="Verdana">Occupation&nbsp;&nbsp; </font></TD> <TD> <font face="Verdana"> &nbsp;<input NAME="Occupation" SIZE="25" tabindex="8" class="quoteform"> </font> </TD> </TR> <TR> <TD ALIGN="right" nowrap> <p> <font face="Verdana">Social Security#&nbsp;&nbsp; </font></TD> <TD> <font face="Verdana"> &nbsp;<!--webbot bot="Validation" s-data-type="Integer" s-number-separators="x" b-value-required="TRUE" i-maximum-length="12" --><input NAME="Social_Securitu" SIZE="25" tabindex="9" class="quoteform" maxlength="12">&nbsp; </font> </TD> </TR> <TR> <TD ALIGN="right" nowrap> <font face="Verdana">Driver License #&nbsp;&nbsp; </font></TD> <TD> <font face="Verdana"> &nbsp;<!--webbot bot="Validation" s-data-type="Integer" s-number-separators="x" b-value-required="TRUE" --><input NAME="Driver_License" SIZE="25" tabindex="10" class="quoteform"> <font color="#0000FF">&nbsp;</font></font></TD> </TR> <TR> <TD ALIGN="right" nowrap> <font face="Verdana">Contact Phone&nbsp;&nbsp; </font></TD> <TD nowrap> <font face="Verdana"> &nbsp;<!--webbot bot="Validation" s-data-type="String" b-allow-digits="TRUE" b-allow-whitespace="TRUE" s-allow-other-chars="()-" b-value-required="TRUE" --><input NAME="Phone" SIZE="25" tabindex="11" class="quoteform"><font color="#0000FF">&nbsp; </font></font></TD> </TR> <TR> <TD ALIGN="right" nowrap> Fax&nbsp;&nbsp; </TD> <TD nowrap> <font face="Verdana"> &nbsp;<!--webbot bot="Validation" s-data-type="String" b-allow-digits="TRUE" b-allow-whitespace="TRUE" s-allow-other-chars="()-" --><input NAME="Fax" SIZE="25" tabindex="12" class="quoteform"><font color="#0000FF">&nbsp;</font></font></TD> </TR> <TR> <TD ALIGN="right" nowrap> <font face="Verdana">E-mail&nbsp;&nbsp; </font></TD> <TD> <font face="Verdana"> &nbsp;<!--webbot bot="Validation" s-data-type="String" b-allow-letters="TRUE" b-allow-digits="TRUE" s-allow-other-chars="@.-_" b-value-required="TRUE" --><input NAME="Email" SIZE="25" tabindex="13" class="quoteform"><font color="#0000FF">&nbsp; </font></font></TD> </TR> </TABLE> </div> &nbsp;<hr class="page-splits"> <div align="left"> &nbsp;</div> <div align="left"> &nbsp;</div> <div align="left"> &nbsp;</div> <div align="left"> <div align="center"> <table border="0" id="table20" style="border-collapse: collapse" cellpadding="3" cellspacing="5"> <tr> <td colspan="4" class="title"> <p align="center"><font size="4" face="Verdana">#2-Motorcycle Information</font></p> <p align="center"><font size="4" face="Verdana">&nbsp;</font>&nbsp;<!--webbot bot="Validation" b-value-required="TRUE" b-disallow-first-item="TRUE" --><select name="Motorcycle_Info" class="dropdown" size="1" tabindex="14" style="background-color: #BAD3F5"> <option selected value="None selected">Motrcycle Information ----&gt;</option> <option>Same as current policy</option> <option>Not Same as current policy</option> </select></p> </td> </tr> <tr> <td colspan="4" align="center"> <table border="0" width="68%" style="border-collapse: collapse" id="table23" cellpadding="0"> <tr> <td> <p align="center"><font color="#F0F0F0" face="Arial">If Motorcycle Information is not the same as your current information, Please fill in Motorcycle Information below.</font><p align="center"> <font color="#F0F0F0" face="Arial">&nbsp;&nbsp; Or if Information is same- go to &quot; Type of Coverage Desired&quot;</font><p align="center"> &nbsp;</td> </tr> </table> </td> </tr> <tr> <td colspan="2"> <p align="center">Unit 1</td> <td valign="top" colspan="2"> <p align="center">Unit 2 (optional)</td> </tr> <tr> <td align="right"><font face="Verdana"> Year</font></td> <td> <font face="Verdana"> &nbsp;<!--webbot bot="Validation" s-data-type="Integer" s-number-separators="x" i-maximum-length="4" s-validation-constraint="Greater than or equal to" s-validation-value="1903" s-validation-constraint="Less than or equal to" s-validation-value="2012" --><INPUT NAME="Year_Unit_1" SIZE=20 tabindex="15" class="quoteform" maxlength="4"></font></td> <td valign="top" align="right"><font face="Verdana"> Year</font></td> <td valign="top"> <font face="Verdana"> &nbsp;<!--webbot bot="Validation" s-data-type="Integer" s-number-separators="x" i-maximum-length="4" --><INPUT NAME="Year_Unit_2" SIZE=20 tabindex="20" class="quoteform" maxlength="4"></font></td> </tr> <tr> <td align="right"><font face="Verdana"> Make</font></td> <td> <font face="Verdana"> &nbsp;<select size="1" name="Make_Unit_1" tabindex="16" class="dropdown"> <option selected>Please Select Manufacturer -&gt;</option> <option>Accurate Cycle Engineering</option> <option>AJS</option> <option>All American Choppers</option> <option>Alphasports</option> <option>Amen Chassis Works</option> <option>American Dirt Bike</option> <option>American Eagle</option> <option>American Image</option> <option>American Ironhorse</option> <option>American King V</option> <option>American Lifan Industry</option> <option>American Motorcycle Corp.</option> <option>American Quantum Cycles</option> <option>American Thunder Tryke</option> <option>Ammex</option> <option>APC Motorcycle Company</option> <option>Apollo Choppers</option> <option>Aprilla</option> <option>Arizona Performance</option> <option>Arlen Ness Motorcycles</option> <option>ATK</option> <option>Attex</option> <option>Backroad Choppers</option> <option>Battistinis Company UK</option> <option>BBR</option> <option>Benelli</option> <option>BBR</option> <option>Beta</option> <option>Big Bear American Choppers</option> <option>Big Boyz Custom Cycles</option> <option>Big Brute</option> <option>Big Dog</option> <option>Big Inch Bikes</option> <option>Big Red Motorcycles</option> <option>Bikers Boulevard</option> <option>Bikers Choice</option> <option>Billy The Kid</option> <option>Bimota</option> <option>Black Swamp Choppers</option> <option>Blata</option> <option>BMC</option> <option>BMW</option> <option>Boar</option> <option>Boom Trikes</option> <option>Boreem</option> <option>Borella</option> <option>Boss Hoss</option> <option>Bourget</option> <option>Boy Toy</option> <option>Brough Superior</option> <option>BSA</option> <option>Buell</option> <option>Burr Built</option> <option>C&amp;S Choppers</option> <option>Cagiva</option> <option>California Customs</option> <option>California MC Co.</option> <option>Cameron</option> <option>Campagna</option> <option>Can-Am</option> <option>Carefree Custom Cycles</option> <option>Carolina Customs</option> <option>Castle</option> <option>CC Cycles</option> <option>CCM (Clews)</option> <option>Chang Jiang</option> <option>Cherokee Motorcycle Co.</option> <option>Chicago Choppers</option> <option>Chop Shop Customs</option> <option>Chopper Works</option> <option>Chopperhead Road</option> <option>Chopperz4life</option> <option>Chrome Horse</option> <option>Circle City Choppers</option> <option>Classic Motor Works</option> <option>Classic Motorcycles</option> <option>Cleveland T-Trike</option> <option>CMH</option> <option>Coast 2 Coast Choppers</option> <option>Cobra Motorcycles</option> <option>Cobra Motors</option> <option>Cobra Trikes</option> <option>Confederate</option> <option>Corbin</option> <option>Covington</option> <option>Crate A Custom Cycle</option> <option>Cruise Dynamic</option> <option>Custom Chrome M/C</option> <option>Cutting Edge</option> <option>Daelim</option> <option>Dan Gurney</option> <option>Darkside Customs</option> <option>Daytec</option> <option>Daytona Beach Bike Works</option> <option>Dazon</option> <option>Death Row Motorcycles</option> <option>Demon Choppers</option> <option>Denali</option> <option>Denver Choppers</option> <option>Desperado</option> <option>Di Blasi</option> <option>Diamo</option> <option>Drakart</option> <option>Ducati</option> <option>Dynamic Choppers</option> <option>Eco-Cycle</option> <option>Ecosse</option> <option>Ecstasy</option> <option>Ecylce</option> <option>Ego</option> <option>Eight Mile Choppers</option> <option>Electra</option> <option>EMB</option> <option>Enfield</option> <option>Esarati</option> <option>Excelsior-Henderson</option> <option>Exile Cycles</option> <option>Exotix</option> <option>Extreme Cycle</option> <option>Ez-Go Workhorse</option> <option>Far</option> <option>Fast Trac</option> <option>Fenris Cycle</option> <option>Flyrite Choppers</option> <option>Force Chopper Design</option> <option>Four Horsemen</option> <option>Gas Gas</option> <option>Global Electric Motors (GEM)</option> <option>Gheezi-Brian</option> <option>Glycing Motor Corp.</option> <option>Grandeur Manufacturing</option> <option>Hard Bikes</option> <option>Harley-Davidson</option> <option>Heald Kit Cycles</option> <option>Hellbound Steel</option> <option>Hesketh</option> <option>Hess-Sexton</option> <option>Hilltop Custom Cycle</option> <option>Hitong</option> <option>Hodaka</option> <option>Hog Belt Bikes</option> <option>Home Made</option> <option>Honda</option> <option>Hoosiers</option> <option>Hunwick</option> <option>Husaberg</option> <option>Husqvarna</option> <option>Hyosung</option> <option>Iacocca</option> <option>Illusion Cycles</option> <option>Illusion</option> <option>IMAC</option> <option>Image Custom Cycles</option> <option>Image Customs</option> <option>Image Cycles</option> <option>Independence Express</option> <option>Indian</option> <option>Iron Eagle Motorcycles</option> <option>Ironworks</option> <option>Jawa/CZ</option> <option>Jim Nasi</option> <option>Johnny Pag</option> <option>Junior Motorcycle Mfg.</option> <option>Kannon</option> <option>Kaotic Kustoms</option> <option>Kasea</option> <option>Kawasaki</option> <option>Kit Bike</option> <option>Kodiak (KMC)</option> <option>Kohler</option> <option>KTM</option> <option>Kymco</option> <option>Lake County Choppers</option> <option>Las Vegas Trikes</option> <option>Laverda</option> <option>Legends Motor Sports</option> <option>LEM</option> <option>Leroy Thompson Choppers</option> <option>Liberator Motorcycles</option> <option>Lifestyle Custom American</option> <option>Lightning</option> <option>Logic Motor Company</option> <option>Longchang</option> <option>Lynx</option> <option>Maico</option> <option>Malaguti</option> <option>Mantis Choppers</option> <option>Max Turbine</option> <option>MC-1</option> <option>Mc Allister Motorcycles</option> <option>MFC</option> <option>Mid-West Choppers</option> <option>Midwest Motorcycle Supply</option> <option>Milwaukee Motorcycle Co.</option> <option>Minneapolis Custom Cycle</option> <option>Minsk</option> <option>Mojo</option> <option>Montesa</option> <option>Moto Guzzi</option> <option>Motor City Mean Machines</option> <option>Motor Trike</option> <option>MV</option> <option>MZ</option> <option>Neval</option> <option>New York Motor Co.</option> <option>Nimbus</option> <option>Norton</option> <option>Nova Trikes</option> <option>Nusun</option> <option>NYC Choppers</option> <option>Oakland County Choppers</option> <option>OC Choppers</option> <option>Oddi Cycles</option> <option>Odyssey Extreme Machines</option> <option>Ossa</option> <option>Owossa Motor Car Co.</option> <option>Oz Trike</option> <option>Oz Bike</option> <option>Pagsta</option> <option>Palmer Industries</option> <option>Panzer</option> <option>Paramount Custom Cycles</option> <option>Patriot</option> <option>Paul Yaffe</option> <option>Pegasus</option> <option>Peugeot</option> <option>Phantom Trikes</option> <option>Phoenix</option> <option>Pitbull</option> <option>Polaris</option> <option>Poor Boy Choppers</option> <option>Power &amp; Chrome</option> <option>Powersled Motorcycles</option> <option>Precision Cycle Works</option> <option>Primo</option> <option>Pro Tune</option> <option>Pro-One</option> <option>Propper Chopper</option> <option>Pure Steel</option> <option>Qingqi Group Co., Ltd.</option> <option>Q-Link</option> <option>Raven Motorcycle</option> <option>Red Horse Motorworks</option> <option>Red Neck Choppers</option> <option>Renegade</option> <option>Revi</option> <option>Revolution Cycle Co.</option> <option>Rewaco</option> <option>Rhino Motorcycles</option> <option>Ridley</option> <option>Rieju</option> <option>Rolling Thunder</option> <option>Route Sixty Six</option> <option>Royal Ryder</option> <option>Rucker Performance</option> <option>Rude American</option> <option>Saxon</option> <option>Sceptre</option> <option>Scorpion</option> <option>Sebring Auto Cycle</option> <option>Secma</option> <option>Sexton Corp.</option> <option>Sherco</option> <option>Sidewinders</option> <option>Simms</option> <option>Sinister Custom Cycles</option> <option>Sinister Motorcycles</option> <option>Sky Team</option> <option>Southwest Choppers</option> <option>Spencer Bowman Customs</option> <option>State Assign VIN</option> <option>Steed</option> <option>Steel Ponies (Death Row)</option> <option>Stroker</option> <option>Surgical Steeds</option> <option>Suzuki</option> <option>Swift</option> <option>Tank Sports</option> <option>Th!nk</option> <option>The Chop Shop</option> <option>The Trike Shop</option> <option>Thoroughbred Motorsports</option> <option>Thunder Bikes</option> <option>Thunder Mountain Cycles</option> <option>Thunderbolt</option> <option>Titan</option> <option>TNT Choppers</option> <option>TM</option> <option>Tomahawk</option> <option>T-Rex</option> <option>Triketec</option> <option>Triumph</option> <option>Ultra Cycles</option> <option>Unilli</option> <option>United Motors</option> <option>Unlimited Dreams</option> <option>Ural</option> <option>Vectrix</option> <option>Vengeance</option> <option>Venom Custom Cycles</option> <option>Vento</option> <option>Venus</option> <option>Vertemati</option> <option>Victory</option> <option>Vincent</option> <option>Viper</option> <option>Viper Motorcycle Co.</option> <option>Viza</option> <option>Von Dutch Kustom</option> <option>VOR</option> <option>V-Twin City</option> <option>West Coast</option> <option>West Coast Choppers</option> <option>White Horse</option> <option>Wild Boar</option> <option>Wild West</option> <option>Wizard Speed &amp; Design</option> <option>Wolf Trikes</option> <option>Wolverine</option> <option>Wrath Manufacturing</option> <option>Xingfu</option> <option>Xingyue Group Co., Ltd.</option> <option>Xtreme Cycle Design</option> <option>Yamaha</option> <option>Yerf Dog</option> <option>Yumbo</option> <option>Zap</option> <option>ZEV</option> <option>Zhongyu</option> <option>Zongshen</option> <option>Other</option> </select> </font></td> <td valign="top" align="right"><font face="Verdana"> Make</font></td> <td valign="top"> <font face="Verdana"> &nbsp;<select size="1" name="Make_Unit_2" tabindex="21" class="dropdown"> <option selected>Please Select Manufacturer -&gt;</option> <option>Accurate Cycle Engineering</option> <option>AJS</option> <option>All American Choppers</option> <option>Alphasports</option> <option>Amen Chassis Works</option> <option>American Dirt Bike</option> <option>American Eagle</option> <option>American Image</option> <option>American Ironhorse</option> <option>American King V</option> <option>American Lifan Industry</option> <option>American Motorcycle Corp.</option> <option>American Quantum Cycles</option> <option>American Thunder Tryke</option> <option>Ammex</option> <option>APC Motorcycle Company</option> <option>Apollo Choppers</option> <option>Aprilla</option> <option>Arizona Performance</option> <option>Arlen Ness Motorcycles</option> <option>ATK</option> <option>Attex</option> <option>Backroad Choppers</option> <option>Battistinis Company UK</option> <option>BBR</option> <option>Benelli</option> <option>BBR</option> <option>Beta</option> <option>Big Bear American Choppers</option> <option>Big Boyz Custom Cycles</option> <option>Big Brute</option> <option>Big Dog</option> <option>Big Inch Bikes</option> <option>Big Red Motorcycles</option> <option>Bikers Boulevard</option> <option>Bikers Choice</option> <option>Billy The Kid</option> <option>Bimota</option> <option>Black Swamp Choppers</option> <option>Blata</option> <option>BMC</option> <option>BMW</option> <option>Boar</option> <option>Boom Trikes</option> <option>Boreem</option> <option>Borella</option> <option>Boss Hoss</option> <option>Bourget</option> <option>Boy Toy</option> <option>Brough Superior</option> <option>BSA</option> <option>Buell</option> <option>Burr Built</option> <option>C&amp;S Choppers</option> <option>Cagiva</option> <option>California Customs</option> <option>California MC Co.</option> <option>Cameron</option> <option>Campagna</option> <option>Can-Am</option> <option>Carefree Custom Cycles</option> <option>Carolina Customs</option> <option>Castle</option> <option>CC Cycles</option> <option>CCM (Clews)</option> <option>Chang Jiang</option> <option>Cherokee Motorcycle Co.</option> <option>Chicago Choppers</option> <option>Chop Shop Customs</option> <option>Chopper Works</option> <option>Chopperhead Road</option> <option>Chopperz4life</option> <option>Chrome Horse</option> <option>Circle City Choppers</option> <option>Classic Motor Works</option> <option>Classic Motorcycles</option> <option>Cleveland T-Trike</option> <option>CMH</option> <option>Coast 2 Coast Choppers</option> <option>Cobra Motorcycles</option> <option>Cobra Motors</option> <option>Cobra Trikes</option> <option>Confederate</option> <option>Corbin</option> <option>Covington</option> <option>Crate A Custom Cycle</option> <option>Cruise Dynamic</option> <option>Custom Chrome M/C</option> <option>Cutting Edge</option> <option>Daelim</option> <option>Dan Gurney</option> <option>Darkside Customs</option> <option>Daytec</option> <option>Daytona Beach Bike Works</option> <option>Dazon</option> <option>Death Row Motorcycles</option> <option>Demon Choppers</option> <option>Denali</option> <option>Denver Choppers</option> <option>Desperado</option> <option>Di Blasi</option> <option>Diamo</option> <option>Drakart</option> <option>Ducati</option> <option>Dynamic Choppers</option> <option>Eco-Cycle</option> <option>Ecosse</option> <option>Ecstasy</option> <option>Ecylce</option> <option>Ego</option> <option>Eight Mile Choppers</option> <option>Electra</option> <option>EMB</option> <option>Enfield</option> <option>Esarati</option> <option>Excelsior-Henderson</option> <option>Exile Cycles</option> <option>Exotix</option> <option>Extreme Cycle</option> <option>Ez-Go Workhorse</option> <option>Far</option> <option>Fast Trac</option> <option>Fenris Cycle</option> <option>Flyrite Choppers</option> <option>Force Chopper Design</option> <option>Four Horsemen</option> <option>Gas Gas</option> <option>Global Electric Motors (GEM)</option> <option>Gheezi-Brian</option> <option>Glycing Motor Corp.</option> <option>Grandeur Manufacturing</option> <option>Hard Bikes</option> <option>Harley-Davidson</option> <option>Heald Kit Cycles</option> <option>Hellbound Steel</option> <option>Hesketh</option> <option>Hess-Sexton</option> <option>Hilltop Custom Cycle</option> <option>Hitong</option> <option>Hodaka</option> <option>Hog Belt Bikes</option> <option>Home Made</option> <option>Honda</option> <option>Hoosiers</option> <option>Hunwick</option> <option>Husaberg</option> <option>Husqvarna</option> <option>Hyosung</option> <option>Iacocca</option> <option>Illusion Cycles</option> <option>Illusion</option> <option>IMAC</option> <option>Image Custom Cycles</option> <option>Image Customs</option> <option>Image Cycles</option> <option>Independence Express</option> <option>Indian</option> <option>Iron Eagle Motorcycles</option> <option>Ironworks</option> <option>Jawa/CZ</option> <option>Jim Nasi</option> <option>Johnny Pag</option> <option>Junior Motorcycle Mfg.</option> <option>Kannon</option> <option>Kaotic Kustoms</option> <option>Kasea</option> <option>Kawasaki</option> <option>Kit Bike</option> <option>Kodiak (KMC)</option> <option>Kohler</option> <option>KTM</option> <option>Kymco</option> <option>Lake County Choppers</option> <option>Las Vegas Trikes</option> <option>Laverda</option> <option>Legends Motor Sports</option> <option>LEM</option> <option>Leroy Thompson Choppers</option> <option>Liberator Motorcycles</option> <option>Lifestyle Custom American</option> <option>Lightning</option> <option>Logic Motor Company</option> <option>Longchang</option> <option>Lynx</option> <option>Maico</option> <option>Malaguti</option> <option>Mantis Choppers</option> <option>Max Turbine</option> <option>MC-1</option> <option>Mc Allister Motorcycles</option> <option>MFC</option> <option>Mid-West Choppers</option> <option>Midwest Motorcycle Supply</option> <option>Milwaukee Motorcycle Co.</option> <option>Minneapolis Custom Cycle</option> <option>Minsk</option> <option>Mojo</option> <option>Montesa</option> <option>Moto Guzzi</option> <option>Motor City Mean Machines</option> <option>Motor Trike</option> <option>MV</option> <option>MZ</option> <option>Neval</option> <option>New York Motor Co.</option> <option>Nimbus</option> <option>Norton</option> <option>Nova Trikes</option> <option>Nusun</option> <option>NYC Choppers</option> <option>Oakland County Choppers</option> <option>OC Choppers</option> <option>Oddi Cycles</option> <option>Odyssey Extreme Machines</option> <option>Ossa</option> <option>Owossa Motor Car Co.</option> <option>Oz Trike</option> <option>Oz Bike</option> <option>Pagsta</option> <option>Palmer Industries</option> <option>Panzer</option> <option>Paramount Custom Cycles</option> <option>Patriot</option> <option>Paul Yaffe</option> <option>Pegasus</option> <option>Peugeot</option> <option>Phantom Trikes</option> <option>Phoenix</option> <option>Pitbull</option> <option>Polaris</option> <option>Poor Boy Choppers</option> <option>Power &amp; Chrome</option> <option>Powersled Motorcycles</option> <option>Precision Cycle Works</option> <option>Primo</option> <option>Pro Tune</option> <option>Pro-One</option> <option>Propper Chopper</option> <option>Pure Steel</option> <option>Qingqi Group Co., Ltd.</option> <option>Q-Link</option> <option>Raven Motorcycle</option> <option>Red Horse Motorworks</option> <option>Red Neck Choppers</option> <option>Renegade</option> <option>Revi</option> <option>Revolution Cycle Co.</option> <option>Rewaco</option> <option>Rhino Motorcycles</option> <option>Ridley</option> <option>Rieju</option> <option>Rolling Thunder</option> <option>Route Sixty Six</option> <option>Royal Ryder</option> <option>Rucker Performance</option> <option>Rude American</option> <option>Saxon</option> <option>Sceptre</option> <option>Scorpion</option> <option>Sebring Auto Cycle</option> <option>Secma</option> <option>Sexton Corp.</option> <option>Sherco</option> <option>Sidewinders</option> <option>Simms</option> <option>Sinister Custom Cycles</option> <option>Sinister Motorcycles</option> <option>Sky Team</option> <option>Southwest Choppers</option> <option>Spencer Bowman Customs</option> <option>State Assign VIN</option> <option>Steed</option> <option>Steel Ponies (Death Row)</option> <option>Stroker</option> <option>Surgical Steeds</option> <option>Suzuki</option> <option>Swift</option> <option>Tank Sports</option> <option>Th!nk</option> <option>The Chop Shop</option> <option>The Trike Shop</option> <option>Thoroughbred Motorsports</option> <option>Thunder Bikes</option> <option>Thunder Mountain Cycles</option> <option>Thunderbolt</option> <option>Titan</option> <option>TNT Choppers</option> <option>TM</option> <option>Tomahawk</option> <option>T-Rex</option> <option>Triketec</option> <option>Triumph</option> <option>Ultra Cycles</option> <option>Unilli</option> <option>United Motors</option> <option>Unlimited Dreams</option> <option>Ural</option> <option>Vectrix</option> <option>Vengeance</option> <option>Venom Custom Cycles</option> <option>Vento</option> <option>Venus</option> <option>Vertemati</option> <option>Victory</option> <option>Vincent</option> <option>Viper</option> <option>Viper Motorcycle Co.</option> <option>Viza</option> <option>Von Dutch Kustom</option> <option>VOR</option> <option>V-Twin City</option> <option>West Coast</option> <option>West Coast Choppers</option> <option>White Horse</option> <option>Wild Boar</option> <option>Wild West</option> <option>Wizard Speed &amp; Design</option> <option>Wolf Trikes</option> <option>Wolverine</option> <option>Wrath Manufacturing</option> <option>Xingfu</option> <option>Xingyue Group Co., Ltd.</option> <option>Xtreme Cycle Design</option> <option>Yamaha</option> <option>Yerf Dog</option> <option>Yumbo</option> <option>Zap</option> <option>ZEV</option> <option>Zhongyu</option> <option>Zongshen</option> <option>Other</option> </select></font></td> </tr> <tr> <td align="right"><font face="Verdana"> Model</font></td> <td> <font face="Verdana"> &nbsp;<!--webbot bot="Validation" s-data-type="String" b-allow-letters="TRUE" b-allow-digits="TRUE" b-allow-whitespace="TRUE" s-allow-other-chars="-/" --><INPUT NAME="Model_Unit_1" SIZE=20 tabindex="17" class="quoteform"></font></td> <td valign="top" align="right"><font face="Verdana"> Model</font></td> <td valign="top"> <font face="Verdana"> &nbsp;<!--webbot bot="Validation" s-data-type="String" b-allow-letters="TRUE" b-allow-digits="TRUE" b-allow-whitespace="TRUE" s-allow-other-chars="-/" --><INPUT NAME="Model_Unit_2" SIZE=20 tabindex="22" class="quoteform"></font></td> </tr> <tr> <td align="right"><font face="Verdana"> CC'S</font></td> <td> <font face="Verdana"> &nbsp;<!--webbot bot="Validation" s-data-type="Integer" s-number-separators="x" i-maximum-length="4" s-validation-constraint="Greater than or equal to" s-validation-value="50" s-validation-constraint="Less than or equal to" s-validation-value="2500" --><INPUT NAME="CC_Unit_1" SIZE=20 tabindex="18" class="quoteform" maxlength="4"></font></td> <td valign="top" align="right"><font face="Verdana"> CC'S</font></td> <td valign="top"> <font face="Verdana"> &nbsp;<!--webbot bot="Validation" s-data-type="Integer" s-number-separators="x" i-maximum-length="4" --><INPUT NAME="CC_Unit_2" SIZE=20 tabindex="23" class="quoteform" maxlength="4"></font></td> </tr> <tr> <td align="right">Vin #&nbsp; </td> <td> &nbsp;<!--webbot bot="Validation" s-data-type="String" b-allow-letters="TRUE" b-allow-digits="TRUE" i-maximum-length="17" --><input type="text" name="VIN_Unit_1" size="20" class="quoteform" tabindex="19" maxlength="17"></td> <td valign="top" align="right">Vin #</td> <td valign="top"> &nbsp;<!--webbot bot="Validation" s-data-type="String" b-allow-letters="TRUE" b-allow-digits="TRUE" i-maximum-length="17" --><input type="text" name="VIN_Unit_2" size="20" class="quoteform" tabindex="24" maxlength="17"></td> </tr> </table> </div> <p>&nbsp;</div> <div align="left"> &nbsp;</div> <hr class="page-splits"> <P align="center"> &nbsp;</P> <div align="center"> <center> <table border="0" id="table3" style="border-collapse: collapse" width="536" cellspacing="5"> <tr> <td width="524" align="center" nowrap colspan="2" class="title"> <p><font face="Verdana" size="4">#3-Type of Coverage Desired</font><p>&nbsp;</td> </tr> <tr> <td width="310" align="center" nowrap class="copytext"> <p align="right"><font face="Verdana"> &nbsp;&nbsp;&nbsp; <font size="2"> What Type of Policy are you looking for?&nbsp;&nbsp; </font></font></p> </td> <center> <td width="207"> &nbsp;<!--webbot bot="Validation" b-value-required="TRUE" b-disallow-first-item="TRUE" --><select name="Type_Of_Policy" class="dropdown" size="1" tabindex="25"> <option selected value="None selected">Please Select One ----&gt;</option> <option>Same as current policy</option> <option>Liability Only</option> <option>Liability,Fire,Theft</option> <option>Liability,Fire,Theft,Collision</option> </select><font face="Verdana"> </font> </td> </tr> </center> <tr> <td width="310" align="center"> <p align="right"> <font face="Verdana"> Pick Limits of Liability and Physical Damage&nbsp;</font></p> </td> <center> <td width="207"> &nbsp;<!--webbot bot="Validation" b-value-required="TRUE" b-disallow-first-item="TRUE" --><select name="Coverage" class="dropdown" size="1" tabindex="26"> <option selected value="None selected">Please Select One ----&gt;</option> <option>Same as current Policy</option> <option>25/50/10 Minimum Coverage</option> <option>50/100/25</option> <option>100/300/50</option> </select><font face="Verdana"> </font> </td> </tr> </center> </center> <tr> <td width="310" align="center"> <p align="right"><font face="Verdana">Please Choose Deductible for Comp. &amp; Coll.&nbsp;</font></p> </td> <center> <td width="207" align="right"> <p align="left"> &nbsp;<!--webbot bot="Validation" b-value-required="TRUE" b-disallow-first-item="TRUE" --><select name="Deductible" class="dropdown" size="1" tabindex="27"> <option selected value="None selected">Please Select One ----&gt;</option> <option>Same as current policy</option> <option>$250</option> <option>$500</option> <option>$1,000</option> </select><font face="Verdana"> </font> </td> </tr> </center> <tr> <td width="310" align="center"> <p align="right"><font face="Verdana">Do you want optional Spousal Liability?&nbsp;</font></td> <center> <td width="207"> &nbsp;<!--webbot bot="Validation" b-value-required="TRUE" b-disallow-first-item="TRUE" --><select name="Spousal_Coverage" class="dropdown" size="1" tabindex="28"> <option selected value="None selected">Please Select One ----&gt;</option> <option>Want Spousal Coverage</option> <option>No Spousal Coverage</option> </select></td> </tr> <tr> <td width="310" align="center"> <p align="right"><font face="Verdana">Do you want optional OBEL (Pedestrian)?&nbsp;&nbsp; </font></td> <center> <td width="207"> &nbsp;<!--webbot bot="Validation" b-value-required="TRUE" b-disallow-first-item="TRUE" --><select name="OBEL" class="dropdown" size="1" tabindex="29"> <option selected value="None selected">Please Select One ----&gt;</option> <option>Want OBEL</option> <option>No OBEL</option> </select></td> </tr> </center> <tr> <td width="310" align="center"> <p align="right"><font face="Verdana">Do you want Optional Medical Payments?&nbsp;&nbsp; </font></td> <center> <td width="207"> &nbsp;<!--webbot bot="Validation" b-value-required="TRUE" b-disallow-first-item="TRUE" --><select name="Medical_Payments" class="dropdown" size="1" tabindex="30"> <option selected value="None selected">Please Select One ----&gt;</option> <option>No Medical Coverage</option> <option>$1,000 Limit</option> <option>$2,500 Limit</option> <option>$5,000 Limit</option> </select></td> </tr> </center> </center> <tr> <td width="310" align="center"> <p align="right"><font face="Verdana">Do You want Optional Roadside Assistance?&nbsp;&nbsp; </font></td> <center> <center> <td width="207"> &nbsp;<!--webbot bot="Validation" b-value-required="TRUE" b-disallow-first-item="TRUE" --><select name="Roadside" class="dropdown" size="1" tabindex="31"> <option selected value="None selected">Please Select One ----&gt;</option> <option>Want Roadside</option> <option>No Roadside</option> </select></td> </tr> </center> </center> <tr> <td width="310" align="center"> <p align="right"><font face="Verdana">Do You want optional Towing?&nbsp;&nbsp; </font></td> <center> <center> <td width="207"> &nbsp;<!--webbot bot="Validation" b-value-required="TRUE" b-disallow-first-item="TRUE" --><select name="Towing" class="dropdown" size="1" tabindex="32"> <option selected value="None selected">Please Select One ----&gt;</option> <option>Want Towing</option> <option>No Towing</option> </select></td> </tr> </table> </center> </div> <p align="center">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </p> <hr class="page-splits"> <div align="center"> <center> <p align="center">&nbsp;</p> <table border="0" width="78%" id="table4" cellspacing="5"> <tr> <td width="96%" align="right" nowrap colspan="2" class="title"> <p align="center"><font face="Verdana" size="4">#4-Underwriting &amp; Discount Questions</font><p align="center">&nbsp;</td> </tr> <tr> <td width="50%" align="right" nowrap> Your Marital Status</td> </center> <td width="39%" align="left"> <p align="left"> &nbsp;<!--webbot bot="Validation" b-value-required="TRUE" b-disallow-first-item="TRUE" --><select name="Marital_Status" class="dropdown" size="1" tabindex="33"> <option selected value="None selected">Please Select One ----&gt;</option> <option>Married</option> <option>Widowed</option> <option>Single</option> </select></p> </td> </tr> <center> <tr> <td width="50%" align="right" nowrap><font face="Verdana">D0 you have a Motorcycle License? </font></td> <td width="39%" align="left"> &nbsp;<!--webbot bot="Validation" b-value-required="TRUE" b-disallow-first-item="TRUE" --><select name="License" class="dropdown" size="1" tabindex="34"> <option selected value="None selected">Please Select One ----&gt;</option> <option>Valid MC License</option> <option>Valid MC Permit</option> <option>Valid Drivers License</option> <option>No License</option> </select></td> </tr> <tr> <td width="50%" align="right" nowrap><font face="Verdana">Years of Motorcycle Experience?</font></td> <td width="39%" align="left"> &nbsp;<!--webbot bot="Validation" b-value-required="TRUE" b-disallow-first-item="TRUE" --><select name="MC_Experience" class="dropdown" size="1" tabindex="35"> <option selected value="None selected">Please Select One ----&gt;</option> <option>None</option> <option>1-5 Years</option> <option>More than 5 years</option> </select></td> </tr> <tr> <td width="50%" align="right" nowrap><font face="Verdana">Is Motorcycle Kept in locked Garaged?&nbsp;</font></td> <td width="39%" align="left"> &nbsp;<!--webbot bot="Validation" b-value-required="TRUE" b-disallow-first-item="TRUE" --><select name="Garage" class="dropdown" size="1" tabindex="36"> <option selected value="None selected">Please Select One ----&gt;</option> <option>Motorcycle Garaged</option> <option>Motorcycle Not Garaged</option> </select></td> </tr> <tr> <td width="50%" align="right" nowrap><font face="Verdana">Major Tickets/Violations in the last 39 months?</font></td> <td width="39%" align="left"> <p align="left"> &nbsp;<!--webbot bot="Validation" b-value-required="TRUE" b-disallow-first-item="TRUE" --><select name="Violations" class="dropdown" size="1" tabindex="37"> <option selected value="None selected">Please Select One ----&gt;</option> <option>No tickets, violations or accidents</option> <option>Minor Violations</option> <option>Major violations-DWI-Suspension</option> <option>Tickets and or accidents</option> </select></td> </tr> <tr> <td width="50%" align="right" nowrap><font face="Verdana">Driver Training or Safety Course Certificate?</font></td> <td width="39%" align="left"> &nbsp;<!--webbot bot="Validation" b-value-required="TRUE" b-disallow-first-item="TRUE" --><select name="Saftey_Certificate" class="dropdown" size="1" tabindex="38"> <option selected value="None selected">Please Select One ----&gt;</option> <option>Have Certificate</option> <option>Don't have Certificate</option> </select></td> </tr> <tr> <td width="50%" align="right" nowrap><font face="Verdana">Member of Motorcycle Rider Group?</font></td> <td width="39%" align="left"> &nbsp;<!--webbot bot="Validation" b-value-required="TRUE" b-disallow-first-item="TRUE" --><select name="Rider_Group" class="dropdown" size="1" tabindex="39"> <option selected value="None selected">Please Select One ----&gt;</option> <option>None</option> <option>Abate</option> <option>AMA</option> <option>BMWOA</option> <option>H.O.G</option> <option>Retreads</option> <option>Other Nationwide Group</option> </select></td> </tr> <tr> <td width="50%" align="right" nowrap><font face="Verdana">Are You a Homeowner?</font></td> <td width="39%" align="left"> &nbsp;<!--webbot bot="Validation" b-value-required="TRUE" b-disallow-first-item="TRUE" --><select name="HomeOwner" class="dropdown" size="1" tabindex="40"> <option selected value="None selected">Please Select One ----&gt;</option> <option>Home Owner</option> <option>Not a Home Owner</option> </select></td> </tr> <tr> <td width="50%" align="right" nowrap>Do you need a Lien holder listed on Policy</td> <td width="39%" align="left"> &nbsp;<!--webbot bot="Validation" b-value-required="TRUE" b-disallow-first-item="TRUE" --><select name="Lien_Holder" class="dropdown" size="1" tabindex="41"> <option selected value="None selected">Please Select One ----&gt;</option> <option>Yes</option> <option>No</option> </select></td> </tr> </table> <p>&nbsp;</p> </center> </div> <hr class="page-splits"> <P align="center" style="margin-top: -15"><font face="Verdana">&nbsp;</font></P> <P align="center" style="margin-top: -15">&nbsp;</P> <P align="center" style="margin-top: -15"><font face="Verdana" size="4">#5-Use text box for any questions or comments.</font></P> <P align="center" style="margin-top: -15"><font face="Verdana" size="2">Please list all tickets, accidents or violations in last 39 months</font></P> <P align="center" style="margin-top: -15"><font face="Verdana">Do you want to list an additional operators?</font></P> <P align="center" style="margin-top: -15">How did you find us?</P> <P align="center" style="margin-top: -15"><font face="Verdana"> <TEXTAREA NAME="Questions_Comments" ROWS=5 COLS=42 tabindex="44" class="textarea"></TEXTAREA> </font></P> <P align="center" style="margin-top: -15">&nbsp;</P> <hr class="page-splits"> <P align="center" style="margin-top: -15">&nbsp;</P> <P align="center" style="margin-top: -15">&nbsp;</P> <div align="center"> <table border="0" id="table5" width="553"> <tr> <td width="94%"> <P style="margin-top: 0"><font face="Verdana">It is our goal to provide you with the best coverage at the lowest price from one of top quality insurance companies we represent. We look forward to serving you in the near future.&nbsp; </font></P> <div align="left"> <table border="0" width="100%" id="table16" style="border-collapse: collapse"> <tr> <td width="93%"><font face="Verdana"> How should we contact you? <INPUT TYPE=CHECKBOX NAME="Contact_Phone" value="ON" tabindex="43">Phone&nbsp; <INPUT TYPE=CHECKBOX NAME="Contact_Fax0" value="ON" tabindex="44">Fax&nbsp; <INPUT TYPE=CHECKBOX NAME="Contact_Email0" value="ON" tabindex="45">E-mail&nbsp; <INPUT TYPE=CHECKBOX NAME="Contact_Postal_Mail0" value="ON" tabindex="46">Regular Mail</font></td> <td width="1%"><font face="Verdana"> &nbsp;</font></td> <td width="2%">&nbsp;</td> <td width="3%">&nbsp;</td> </tr> <tr> <td colspan="4">&nbsp;<p><font face="Verdana">Thank you for taking the time to fill out this form -worksheet. We will use the information you supplied along with your DMV records and your consumer reports which include your credit and financial responsibility information to review your policy and obtain an insurance quote for you. This information will be kept confidential and is used by us and the insurance companies we represent for rating&nbsp; purposes only </font><font face="Arial" size="2">and will not be shared with any one else</font><font face="Verdana">. By submitting this form you are authorizing us to access your information, review policy and provide you with a quote. </font> </td> </tr> </table> </div> <P style="margin-top: -15">&nbsp;</P></td> </tr> </table> </div> <div align="center"> <table border="0" id="table8" width="101%"> <tr> <td>&nbsp;</td> </tr> <tr> <td><font face="Verdana">Kenneth Veale</font></td> </tr> <tr> <td>&nbsp;</td> </tr> <tr> <td> <p style="margin-top: -20"><font face="Verdana">Ryde Insurance Agency </font></p> <P style="margin-top: -20"> <font face="Verdana">Ryde Insurance Agency </font> </P> <P style="margin-top: -20"> <font face="Verdana">106 W Broadway </font> </P> <P style="margin-top: -20"> <font face="Verdana">Port Jefferson, New York, 11777</font></P> <p style="margin-top: -20"><font face="Verdana">&nbsp;</font></p> <p>&nbsp;</td> </tr> <tr> <td> <p style="margin-top: -20"><font face="Verdana">E-mail: Rydemc@aol.com </font></p> <p style="margin-top: -20"><font face="Verdana">E-mail: <a href="mailto:Rydemc@aol.com">Ryde Insurance Agency</a> </font></p> <p style="margin-top: -20"><font face="Verdana">Phone:631-476-0722 </font></p> <p style="margin-top: -20"><font face="Verdana">Fax: 631-476-1378</font></p> <p style="margin-top: -20">&nbsp;</p> <p style="margin-top: -20"> <input TYPE="submit" VALUE="Submit Form" class="button" tabindex="47"> <input TYPE="reset" VALUE="Reset Form" class="button" tabindex="48"><font face="Verdana">&nbsp; </font> </p> <p style="margin-top: -20"> &nbsp;</p> <p>Please Fax your current insurance Declaration Page to us at 631-476-1378. The Declaration Page is the page that shows your coverage and what you pay for the coverage. We will get back to you in a timely manner.&nbsp;</td> </tr> </table> </div> <p> <br> &nbsp;</td></tr></table> <!-- CONTACT TABLE 1 --> </form> <!-- TO REMOVE FORM DELETE TEXT BETWEEN THESE COMMENTS --> </td></tr></table> <!-- QUOTE FORM TABLE --> </center> <br><br> </td></tr></table> <!-- MAIN TABLE--> </CENTER> <br> </td><td align="left" valign="top" width="120"> <script language="JavaScript" type="text/javascript" src="menu.js"></script> <script language="JavaScript" type="text/javascript" src="menu_pictures.js"></script> <script language="JavaScript" type="text/javascript" src="menu_lower.js"></script> </td></tr></table> <!-- SPLIT TABLE--> <br><br><br><br> </TD></TR><TR><TD valign="BOTTOM"><!-- OUTER TABLE--> <!-- COPYRIGHT --> <TABLE cellpadding="4" cellspacing="0" border="0" width="100%" class="footertext"><tr><td WIDTH="3"> <img src="picts/spacer.gif" HEIGHT="10" WIDTH="3" border="0" alt="image"><br> </td><td align="left" valign="top"> <script language="JavaScript" type="text/javascript" src="copyright.js"></script> </td><td align="RIGHT" valign="top"> <script language="JavaScript" type="text/javascript" src="copyright-allwebco.js"></script> </TD><td WIDTH="3"> <img src="picts/spacer.gif" HEIGHT="10" WIDTH="3" border="0" alt="image"><br> </td></tr></table> <!-- COPYRIGHT --> </td></tr></table> <!-- OUTER TABLE--> <!-- Begin ContactMe Middle Left Button --> <script type="text/javascript"> var _cmo = { form: '4d5ee169f894ae6fe2000cda', text: 'Contact', align: 'left', valign: 'bottom', lang: 'en', background_color: '#003C68' }; (function() { var cms = document.createElement('script'); cms.type = 'text/javascript'; cms.async = true; cms.src = ('https:' == document.location.protocol ? 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