document.write("<title>Contact Gateway Insurance</title>\n");
document.write("<FONT face=Verdana size=2>Thank you for your interest in Gateway Insurance. Please complete the following information and click 'Submit'. (*= required field)<BR></FONT><form  method=POST action=\"http://www.betagraph-host.com/cgi-scr"+"ipt/csFormbuilder/csFormbuilder.cgi\" name=\"form_17\"  >\n");
document.write("<input type=hidden name=form-id value=\"17\">\n");
document.write("<input type=hidden name=command value=\"mailform\">\n");
document.write("<link rel=\"stylesheet\" type=\"text/css\" href=\"http://www.betagraph-host.com/cgi-scr"+"ipt/csFormbuilder/forms/GatewayContact.css\">\n");
document.write("<table border=\"0\" cellspacing=\"0\" cellpadding=\"3\">\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\" ></td><td align=left valign=top nowrap class=\"textLabel\"><table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"left\">*Firstname</td>\n");
document.write("</tr>\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"firstname\"  size=\"23\"   maxlength=\"20\" ></td>\n");
document.write("</tr>\n");
document.write("</table>  <table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"left\">*Last Name</td>\n");
document.write("</tr>\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"lastname\"  size=\"23\"   maxlength=\"20\" ></td>\n");
document.write("</tr>\n");
document.write("</table><!-- tr ph 1--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\" ></td><td align=left valign=top nowrap class=\"textLabel\"><table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"left\">Company</td>\n");
document.write("</tr>\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"Company\"  size=\"50\"  ><a href=\"#\" tabindex=999><img src=\"http://www.betagraph-host.com/cgi-scr"+"ipt/csFormbuilder/images/desc.gif\" width=16 height=16 alt=\"Commercial insurance customers, please provide company name.\" border=0></a></td>\n");
document.write("</tr>\n");
document.write("</table> <!-- tr ph 2--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\" ></td><td align=left valign=top nowrap class=\"textLabel\"><table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"left\">*Address</td>\n");
document.write("</tr>\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"Address1\"  size=\"50\"  ></td>\n");
document.write("</tr>\n");
document.write("</table> <!-- tr ph 3--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\" ></td><td align=left valign=top nowrap class=\"textLabel\"><table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"left\">Address2</td>\n");
document.write("</tr>\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"Address2\"  size=\"50\"  ></td>\n");
document.write("</tr>\n");
document.write("</table> <!-- tr ph 4--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\" ></td><td align=left valign=top nowrap class=\"textLabel\"><table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"left\">*City</td>\n");
document.write("</tr>\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"city\"  size=\"20\"  ></td>\n");
document.write("</tr>\n");
document.write("</table>  <table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"left\">*State </td>\n");
document.write("</tr>\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\"><select name=\"State\"  size=\"1\"   onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\">\n");
document.write("<option value=\"\"></option>\n");
document.write("<option value=\"AK\">AK-Alaska</option>\n");
document.write("<option value=\"AL\">AL-Alabama</option>\n");
document.write("<option value=\"AR\">AR-Arkansas</option>\n");
document.write("<option value=\"AZ\">AZ-Arizona</option>\n");
document.write("<option value=\"CA\">CA-California</option>\n");
document.write("<option value=\"CO\">CO-Colorado</option>\n");
document.write("<option value=\"CT\">CT-Connecticut</option>\n");
document.write("<option value=\"DC\">DC-District of Columbia</option>\n");
document.write("<option value=\"DE\">DE-Delaware</option>\n");
document.write("<option value=\"FL\">FL-Florida</option>\n");
document.write("<option value=\"GA\">GA-Georgia</option>\n");
document.write("<option value=\"HI\">HI-Hawaii</option>\n");
document.write("<option value=\"IA\">IA-Iowa</option>\n");
document.write("<option value=\"ID\">ID-Idaho</option>\n");
document.write("<option value=\"IL\">IL-Illinois</option>\n");
document.write("<option value=\"IN\">IN-Indiana</option>\n");
document.write("<option value=\"KS\">KS-Kansas</option>\n");
document.write("<option value=\"KY\">KY-Kentucky</option>\n");
document.write("<option value=\"LA\">LA-Louisiana</option>\n");
document.write("<option value=\"MA\">MA-Massachusetts</option>\n");
document.write("<option value=\"MD\">MD-Maryland</option>\n");
document.write("<option value=\"ME\">ME-Maine</option>\n");
document.write("<option value=\"MI\">MI-Michigan</option>\n");
document.write("<option value=\"MN\">MN-Minnesota</option>\n");
document.write("<option value=\"MO\">MO-Missouri</option>\n");
document.write("<option value=\"MS\">MS-Mississippi</option>\n");
document.write("<option value=\"MT\">MT-Montana</option>\n");
document.write("<option value=\"NC\">NC-North Carolina</option>\n");
document.write("<option value=\"ND\">ND-North Dakota</option>\n");
document.write("<option value=\"NE\">NE-Nebraska</option>\n");
document.write("<option value=\"NH\">NH-New Hampshire</option>\n");
document.write("<option value=\"NJ\">NJ-New Jersey</option>\n");
document.write("<option value=\"NM\">NM-New Mexico</option>\n");
document.write("<option value=\"NV\">NV-Nevada</option>\n");
document.write("<option value=\"NY\">NY-New York</option>\n");
document.write("<option value=\"OH\">OH-Ohio</option>\n");
document.write("<option value=\"OK\">OK-Oklahoma</option>\n");
document.write("<option value=\"OR\">OR-Oregon</option>\n");
document.write("<option value=\"OT\">OT-Other</option>\n");
document.write("<option value=\"PA\">PA-Pennsylvania</option>\n");
document.write("<option value=\"RI\">RI-Rhode Island</option>\n");
document.write("<option value=\"SC\">SC-South Carolina</option>\n");
document.write("<option value=\"SD\">SD-South Dakota</option>\n");
document.write("<option value=\"TN\">TN-Tennessee</option>\n");
document.write("<option value=\"TX\">TX-Texas</option>\n");
document.write("<option value=\"UT\">UT-Utah</option>\n");
document.write("<option value=\"VA\">VA-Virginia</option>\n");
document.write("<option value=\"VT\">VT-Vermont</option>\n");
document.write("<option value=\"WA\">WA-Washington</option>\n");
document.write("<option value=\"WI\">WI-Wisconsin</option>\n");
document.write("<option value=\"WV\">WV-West Virginia</option>\n");
document.write("<option value=\"WY\">WY-Wyoming</option>\n");
document.write("</select>&nbsp;</td>\n");
document.write("</tr>\n");
document.write("</table> <table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"left\">*Zip Code</td>\n");
document.write("</tr>\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"Zipcode\"  size=\"6\"  ></td>\n");
document.write("</tr>\n");
document.write("</table><!-- tr ph 7--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\" ></td><td align=left valign=top nowrap class=\"textLabel\"><table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"left\">Phone:</td>\n");
document.write("</tr>\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\">\n");
document.write("	      <table border=\"0\" cellspacing=\"0\">\n");
document.write("	        <tr>\n");
document.write("	          <td valign=\"middle\" align=\"center\" class=\"textLabel\" nowrap>(</td>\n");
document.write("	          <td valign=\"middle\" align=\"center\" class=\"textLabel\" nowrap><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"Phone_1\" size=\"3\" maxlength=\"3\"></td>\n");
document.write("	          <td valign=\"middle\" align=\"center\" class=\"textLabel\" nowrap>)</td>\n");
document.write("	          <td valign=\"middle\" align=\"center\" class=\"textLabel\" nowrap>&nbsp;</td>\n");
document.write("	          <td valign=\"middle\" align=\"center\" class=\"textLabel\" nowrap><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"Phone_2\" size=\"3\" maxlength=\"3\"></td>\n");
document.write("	          <td valign=\"middle\" align=\"center\" class=\"textLabel\" nowrap>-</td>\n");
document.write("	          <td valign=\"middle\" align=\"center\" class=\"textLabel\" nowrap><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"Phone_3\" size=\"4\" maxlength=\"4\"></td>\n");
document.write("	        </tr>\n");
document.write("      </table>\n");
document.write("      </td>\n");
document.write("</tr>\n");
document.write("</table>  <table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"left\">Business Phone:</td>\n");
document.write("</tr>\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\">\n");
document.write("	      <table border=\"0\" cellspacing=\"0\">\n");
document.write("	        <tr>\n");
document.write("	          <td valign=\"middle\" align=\"center\" class=\"textLabel\" nowrap>(</td>\n");
document.write("	          <td valign=\"middle\" align=\"center\" class=\"textLabel\" nowrap><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"BusPhone_1\" size=\"3\" maxlength=\"3\"></td>\n");
document.write("	          <td valign=\"middle\" align=\"center\" class=\"textLabel\" nowrap>)</td>\n");
document.write("	          <td valign=\"middle\" align=\"center\" class=\"textLabel\" nowrap>&nbsp;</td>\n");
document.write("	          <td valign=\"middle\" align=\"center\" class=\"textLabel\" nowrap><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"BusPhone_2\" size=\"3\" maxlength=\"3\"></td>\n");
document.write("	          <td valign=\"middle\" align=\"center\" class=\"textLabel\" nowrap>-</td>\n");
document.write("	          <td valign=\"middle\" align=\"center\" class=\"textLabel\" nowrap><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"BusPhone_3\" size=\"4\" maxlength=\"4\"></td>\n");
document.write("          	  <td valign=\"middle\" align=\"center\" class=\"textLabel\" nowrap>Ext.</td>\n");
document.write("          	  <td valign=\"middle\" align=\"center\" class=\"textLabel\" nowrap><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"BusPhone_4\" size=\"5\" maxlength=20></td>	          \n");
document.write("	        </tr>\n");
document.write("      </table>\n");
document.write("      </td>\n");
document.write("</tr>\n");
document.write("</table><!-- tr ph 9--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\" ></td><td align=left valign=top nowrap class=\"textLabel\"><table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"left\">*Email:</td>\n");
document.write("</tr>\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"Email\"  size=\"23\"  ></td>\n");
document.write("</tr>\n");
document.write("</table>  <table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"left\">*Verify Email:</td>\n");
document.write("</tr>\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=\"text\" name=\"Email_Verify\"  size=\"23\"  ></td>\n");
document.write("</tr>\n");
document.write("</table><!-- tr ph 10--></td></tr>\n");
document.write("<tr><td class=\"textLabel\" colspan=2  height=\"3\" ></td></tr><tr><td class=\"textLabel\" colspan=2><hr width=\"100%\" size=\"1\" color=\"000000\" align=\"left\"></td></tr><tr><td nowrap class=\"textLabel\" align=\"left\"  valign=\"top\" ></td><td align=left valign=top nowrap class=\"textLabel\"><table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"left\">Preferred Contact Method </td>\n");
document.write("</tr>\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\"><table border=0 cellspacing=2 cellpadding=0><tr><td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=radio name=\"ContactMethod\" value=\"Email\"></td><td class=\"textLabel\">Email</td>\n");
document.write("<td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=radio name=\"ContactMethod\" value=\"Home Phone\"></td><td class=\"textLabel\">Home Phone</td>\n");
document.write("<td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=radio name=\"ContactMethod\" value=\"Business Phone\"></td><td class=\"textLabel\">Business Phone</td>\n");
document.write("</tr></table>\n");
document.write("</td>\n");
document.write("</tr>\n");
document.write("</table> <!-- tr ph 11--></td></tr>\n");
document.write("<tr><td nowrap class=\"textLabel\" align=\"left\"  valign=\"top\" ></td><td align=left valign=top nowrap class=\"textLabel\"><table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"left\">Preferred Phone Contact Time </td>\n");
document.write("</tr>\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\"><table border=0 cellspacing=2 cellpadding=0><tr><td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=radio name=\"ContactTime\" value=\"Morning\"></td><td class=\"textLabel\">Morning</td>\n");
document.write("<td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=radio name=\"ContactTime\" value=\"Afternoon\"></td><td class=\"textLabel\">Afternoon</td>\n");
document.write("<td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=radio name=\"ContactTime\" value=\"Evening\"></td><td class=\"textLabel\">Evening</td>\n");
document.write("<td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=radio name=\"ContactTime\" value=\"Weekend\"></td><td class=\"textLabel\">Weekend</td>\n");
document.write("</tr></table>\n");
document.write("</td>\n");
document.write("</tr>\n");
document.write("</table> <!-- tr ph 12--></td></tr>\n");
document.write("<tr><td class=\"textLabel\" colspan=2><hr width=\"100%\" size=\"1px\" color=\"000000\" align=\"left\"></td></tr><tr><td nowrap class=\"textLabel\" align=\"right\"  valign=\"top\" ></td><td align=left valign=top nowrap class=\"textLabel\"><table align=left border=\"0\" cellspacing=\"0\" cellpadding=\"0\">\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\" align=\"right\">I'd like information about </td>\n");
document.write("</tr>\n");
document.write("<tr>\n");
document.write("<td nowrap class=\"textLabel\"><table border=0 cellspacing=2 cellpadding=0><tr><td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=checkbox name=\"InfoDesired\" value=\"Insurance Review\"></td><td class=\"textLabel\">Insurance Review</td></tr>\n");
document.write("<tr><td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=checkbox name=\"InfoDesired\" value=\"Homeowner Insurance\"></td><td class=\"textLabel\">Homeowner Insurance</td></tr>\n");
document.write("<tr><td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=checkbox name=\"InfoDesired\" value=\"Auto Insurance\"></td><td class=\"textLabel\">Auto Insurance</td></tr>\n");
document.write("<tr><td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=checkbox name=\"InfoDesired\" value=\"Financial Planning\"></td><td class=\"textLabel\">Financial Planning</td></tr>\n");
document.write("<tr><td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=checkbox name=\"InfoDesired\" value=\"Commercial Insurance\"></td><td class=\"textLabel\">Commercial Insurance</td></tr>\n");
document.write("<tr><td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=checkbox name=\"InfoDesired\" value=\"Employee Benefits\"></td><td class=\"textLabel\">Employee Benefits</td></tr>\n");
document.write("<tr><td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=checkbox name=\"InfoDesired\" value=\"Condo-HOA Insurance\"></td><td class=\"textLabel\">Condo-HOA Insurance</td></tr>\n");
document.write("<tr><td class=\"textLabel\"><input onfocus=\"className='textFieldFocus'\" onblur=\"className='textField'\" class=\"textField\" type=checkbox name=\"InfoDesired\" value=\"\"></td><td class=\"textLabel\">Other: <input type=text name=\"InfoDesired\"  size=\"10\"  ></td></tr>\n");
document.write("</table>\n");
document.write("</td>\n");
document.write("</tr>\n");
document.write("</table> <!-- tr ph 13--></td></tr>\n");
document.write("<tr><td colspan=2 align=\"left\"><input onmouseover=\"className='buttonfieldFocus'\" onmouseout=\"className='buttonfield'\" class=\"buttonfield\" type=button value=\"Back\" onClick=\"history.back();\"><input onmouseover=\"className='buttonfieldFocus'\" onmouseout=\"className='buttonfield'\" class=\"buttonfield\" type=submit value=\"Submit\"></td></tr>\n");
document.write("</table>\n");
document.write("</form>\n");