document.write("<div class=\"rwspage\">\n<h1>Lessert Insurance</h1>\n<h3></h3>\n<div><font face=\"arial,helvetica,sans-serif\" size=\"3\">Because Lessert Insurance works with a variety of insurance companies, we can provide you with the insurance coverage you need at a price you can afford.&nbsp; To find out how we compare with other agencies, please take a few minutes to provide information about yourself and your family or business and the type of insurance you are interested in.&nbsp; We\'ll contact you within two days to provide you with a quote.&nbsp; </font></div>\n</div>\n<div id=\"rwsform_95a78505-0f94-4035-9a9f-a8ca8aeb6983\">\n<form id=\"rws_form\" action=\"http://www.radiowebservices.com/forms/post/95a78505-0f94-4035-9a9f-a8ca8aeb6983\" method=\"post\">\n<div class=\"rws_form_field\">\n<label for=\"form_baa052f6-ac5f-4a18-a72b-cf1f5653b99d\"><font color=\"#cc0000\">Name</font></label>\n<input type=\"text\" class=\"rwsform_textinput\" name=\"rwsform[baa052f6-ac5f-4a18-a72b-cf1f5653b99d]\" id=\"form_baa052f6-ac5f-4a18-a72b-cf1f5653b99d\" value=\"\">\n</div>\n<div class=\"rws_form_field\">\n<label for=\"form_f518287f-726b-483d-820b-506e7d54dc77\"><font color=\"#cc0000\">Address</font></label>\n<input type=\"text\" class=\"rwsform_textinput\" name=\"rwsform[f518287f-726b-483d-820b-506e7d54dc77]\" id=\"form_f518287f-726b-483d-820b-506e7d54dc77\" value=\"\">\n</div>\n<div class=\"rws_form_field\">\n<label for=\"form_f71f8ace-c686-4b5e-8117-105071584fb8\"><font color=\"#cc0000\">City</font></label>\n<input type=\"text\" class=\"rwsform_textinput\" name=\"rwsform[f71f8ace-c686-4b5e-8117-105071584fb8]\" id=\"form_f71f8ace-c686-4b5e-8117-105071584fb8\" value=\"\">\n</div>\n<div class=\"rws_form_field\">\n<label for=\"form_377b6771-bece-4bff-8f35-9a3be81e1aaa\"><font color=\"#cc0000\">State</font></label>\n<input type=\"text\" class=\"rwsform_textinput\" name=\"rwsform[377b6771-bece-4bff-8f35-9a3be81e1aaa]\" id=\"form_377b6771-bece-4bff-8f35-9a3be81e1aaa\" value=\"\">\n</div>\n<div class=\"rws_form_field\">\n<label for=\"form_dc70de71-60f5-4169-a727-c48aec6577ed\"><font color=\"#cc0000\">Zip</font></label>\n<input type=\"text\" class=\"rwsform_textinput\" name=\"rwsform[dc70de71-60f5-4169-a727-c48aec6577ed]\" id=\"form_dc70de71-60f5-4169-a727-c48aec6577ed\" value=\"\">\n</div>\n<div class=\"rws_form_field\">\n<label for=\"form_3ee81449-4386-48fc-b21c-36cb45faa542\">Home Phone</label>\n<input type=\"text\" class=\"rwsform_textinput\" name=\"rwsform[3ee81449-4386-48fc-b21c-36cb45faa542]\" id=\"form_3ee81449-4386-48fc-b21c-36cb45faa542\" value=\"\">\n</div>\n<div class=\"rws_form_field\">\n<label for=\"form_4a9f77e6-abcd-49d2-b118-e729ee27be78\">Work Phone</label>\n<input type=\"text\" class=\"rwsform_textinput\" name=\"rwsform[4a9f77e6-abcd-49d2-b118-e729ee27be78]\" id=\"form_4a9f77e6-abcd-49d2-b118-e729ee27be78\" value=\"\">\n</div>\n<div class=\"rws_form_field\">\n<label for=\"form_cab5d344-0c22-479e-b274-2ffe137bd756\">Fax Number</label>\n<input type=\"text\" class=\"rwsform_textinput\" name=\"rwsform[cab5d344-0c22-479e-b274-2ffe137bd756]\" id=\"form_cab5d344-0c22-479e-b274-2ffe137bd756\" value=\"\">\n</div>\n<div class=\"rws_form_field\">\n<label for=\"form_4884d931-ac15-4d32-8930-c0d8f12cdd0e\">Email Address</label>\n<input type=\"text\" class=\"rwsform_textinput\" name=\"rwsform[4884d931-ac15-4d32-8930-c0d8f12cdd0e]\" id=\"form_4884d931-ac15-4d32-8930-c0d8f12cdd0e\" value=\"\">\n</div>\n<div class=\"rws_form_field\">\n<label for=\"form_03d13db0-02a2-42e9-becc-511071096095\"><font color=\"#cc0000\">Please select the type(s) of coverage you are interested in</font></label>\n<div class=\"field_option\"><input type=\"checkbox\" name=\"rwsform[03d13db0-02a2-42e9-becc-511071096095][]\" value=\"Auto\">Auto</div><div class=\"field_option\"><input type=\"checkbox\" name=\"rwsform[03d13db0-02a2-42e9-becc-511071096095][]\" value=\"Commercial\">Commercial</div><div class=\"field_option\"><input type=\"checkbox\" name=\"rwsform[03d13db0-02a2-42e9-becc-511071096095][]\" value=\"Farm/Ranch/Feedlot\">Farm/Ranch/Feedlot</div><div class=\"field_option\"><input type=\"checkbox\" name=\"rwsform[03d13db0-02a2-42e9-becc-511071096095][]\" value=\"Critical Care\">Critical Care</div><div class=\"field_option\"><input type=\"checkbox\" name=\"rwsform[03d13db0-02a2-42e9-becc-511071096095][]\" value=\"Home\">Home</div><div class=\"field_option\"><input type=\"checkbox\" name=\"rwsform[03d13db0-02a2-42e9-becc-511071096095][]\" value=\"Fine Arts\">Fine Arts</div><div class=\"field_option\"><input type=\"checkbox\" name=\"rwsform[03d13db0-02a2-42e9-becc-511071096095][]\" value=\"Animal Mortality\">Animal Mortality</div><div class=\"field_option\"><input type=\"checkbox\" name=\"rwsform[03d13db0-02a2-42e9-becc-511071096095][]\" value=\"Disability\">Disability</div><div class=\"field_option\"><input type=\"checkbox\" name=\"rwsform[03d13db0-02a2-42e9-becc-511071096095][]\" value=\"Flood\">Flood</div><div class=\"field_option\"><input type=\"checkbox\" name=\"rwsform[03d13db0-02a2-42e9-becc-511071096095][]\" value=\"Custom Harvest\">Custom Harvest</div><div class=\"field_option\"><input type=\"checkbox\" name=\"rwsform[03d13db0-02a2-42e9-becc-511071096095][]\" value=\"Day Care\">Day Care</div><div class=\"field_option\"><input type=\"checkbox\" name=\"rwsform[03d13db0-02a2-42e9-becc-511071096095][]\" value=\"Life\">Life</div><div class=\"field_option\"><input type=\"checkbox\" name=\"rwsform[03d13db0-02a2-42e9-becc-511071096095][]\" value=\"Umbrella\">Umbrella</div><div class=\"field_option\"><input type=\"checkbox\" name=\"rwsform[03d13db0-02a2-42e9-becc-511071096095][]\" value=\"Mobile Home\">Mobile Home</div><div class=\"field_option\"><input type=\"checkbox\" name=\"rwsform[03d13db0-02a2-42e9-becc-511071096095][]\" value=\"Bonds\">Bonds</div><div class=\"field_option\"><input type=\"checkbox\" name=\"rwsform[03d13db0-02a2-42e9-becc-511071096095][]\" value=\"Long Term Care\">Long Term Care</div><div class=\"field_option\"><input type=\"checkbox\" name=\"rwsform[03d13db0-02a2-42e9-becc-511071096095][]\" value=\"Renters\">Renters</div><div class=\"field_option\"><input type=\"checkbox\" name=\"rwsform[03d13db0-02a2-42e9-becc-511071096095][]\" value=\"Motorcycle\">Motorcycle</div><div class=\"field_option\"><input type=\"checkbox\" name=\"rwsform[03d13db0-02a2-42e9-becc-511071096095][]\" value=\"Annuities/Mutual Funds\">Annuities/Mutual Funds</div><div class=\"field_option\"><input type=\"checkbox\" name=\"rwsform[03d13db0-02a2-42e9-becc-511071096095][]\" value=\"Medicare Supplements\">Medicare Supplements</div><div class=\"field_option\"><input type=\"checkbox\" name=\"rwsform[03d13db0-02a2-42e9-becc-511071096095][]\" value=\"Watercraft\">Watercraft</div><div class=\"field_option\"><input type=\"checkbox\" name=\"rwsform[03d13db0-02a2-42e9-becc-511071096095][]\" value=\"Retirement\">Retirement</div><div class=\"field_option\"><input type=\"checkbox\" name=\"rwsform[03d13db0-02a2-42e9-becc-511071096095][]\" value=\"Health-Individual\">Health-Individual</div><div class=\"field_option\"><input type=\"checkbox\" name=\"rwsform[03d13db0-02a2-42e9-becc-511071096095][]\" value=\"Health-Group\">Health-Group</div></div>\n<div class=\"rws_form_field\">\n<label for=\"form_3bcab033-f770-41f0-aeb3-be5162f8aab2\">How would you like to be contacted?</label>\n<div class=\"field_option\"><input type=\"radio\" name=\"rwsform[3bcab033-f770-41f0-aeb3-be5162f8aab2]\" value=\"Email\">Email</div><div class=\"field_option\"><input type=\"radio\" name=\"rwsform[3bcab033-f770-41f0-aeb3-be5162f8aab2]\" value=\"Phone\">Phone</div><div class=\"field_option\"><input type=\"radio\" name=\"rwsform[3bcab033-f770-41f0-aeb3-be5162f8aab2]\" value=\"Physical Mail\">Physical Mail</div></div>\n<div class=\"rws_form_field\">\n<label for=\"form_766d67af-29de-46a4-9bc7-aadec9542263\">Special Instructions or Comments?</label>\n<textarea name=\"rwsform[766d67af-29de-46a4-9bc7-aadec9542263]\" id=\"form_766d67af-29de-46a4-9bc7-aadec9542263\" rows=\"10\" cols=\"45\"></textarea>\n</div>\n<input type=\"submit\" value=\"Submit Entry\" id=\"rwsf_submit\">\n</form>\n</div>\n");