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		<field required="true" type="text" name="last-name" placeholder="Last Name*" label="Last Name"/>
		<field required="true" type="text" name="phone-number" placeholder="Phone Number*" label="Phone Number"/>
		<field required="true" type="text" name="email-address" placeholder="Email Address*" label="Email Address"/>
		<field required="true" type="text" name="address" placeholder="Address*" label="Address"/>
		<field required="true" type="text" name="city" placeholder="City*" label="City"/>
		<field required="true" type="text" name="state" placeholder="State*" label="State"/>
		<field required="true" type="text" name="zip-code" placeholder="Zip Code*" label="Zip Code"/>
		<field type="text" name="age" placeholder="Age" label="Age"/>
		<field type="radio-group" name="gender" label="Gender">
			<option selected="true" value="Male">Male</option>
			<option value="Female">Female</option>
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		<field type="radio-group" name="are-you-a-smoker" label="Are you a smoker?">
			<option value="Yes">Yes</option>
			<option selected="true" value="No">No</option>
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		<field type="select" name="amount-of-coverage-requested" label="Amount of Coverage Requested">
			<option selected="true" value="">Select One</option>
			<option value="$100,000">$100,000</option>
			<option value="$150,000">$150,000</option>
			<option value="$200,000">$200,000</option>
			<option value="$250,000">$250,000</option>
			<option value="$300,000">$300,000</option>
			<option value="$350,000">$350,000</option>
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			<option value="$700,000">$700,000</option>
			<option value="$750,000">$750,000</option>
			<option value="$800,000">$800,000</option>
			<option value="$850,000">$850,000</option>
			<option value="$900,000">$900,000</option>
			<option value="$950,000">$950,000</option>
			<option value="$1,000,000">$1,000,000</option>
			<option value="$1,100,000">$1,100,000</option>
			<option value="$1,200,000">$1,200,000</option>
			<option value="$1,300,000">$1,300,000</option>
			<option value="$1,400,000">$1,400,000</option>
			<option value="$1,500,000">$1,500,000</option>
			<option value="$1,600,000">$1,600,000</option>
			<option value="$1,700,000">$1,700,000</option>
			<option value="$1,800,000">$1,800,000</option>
			<option value="$1,900,000">$1,900,000</option>
			<option value="$2,000,000">$2,000,000</option>
			<option value="$2,100,000">$2,100,000</option>
			<option value="$2,200,000">$2,200,000</option>
			<option value="$2,300,000">$2,300,000</option>
			<option value="$2,400,000">$2,400,000</option>
			<option value="$2,500,000">$2,500,000</option>
			<option value="$2,600,000">$2,600,000</option>
			<option value="$2,700,000">$2,700,000</option>
			<option value="$2,800,000">$2,800,000</option>
			<option value="$2,900,000">$2,900,000</option>
			<option value="$3,000,000">$3,000,000</option>
			<option value="$3,100,000">$3,100,000</option>
			<option value="$3,200,000">$3,200,000</option>
			<option value="$3,300,000">$3,300,000</option>
			<option value="$3,400,000">$3,400,000</option>
			<option value="$3,500,000">$3,500,000</option>
			<option value="$3,600,000">$3,600,000</option>
			<option value="$3,700,000">$3,700,000</option>
			<option value="$3,800,000">$3,800,000</option>
			<option value="$3,900,000">$3,900,000</option>
			<option value="$4,000,000">$4,000,000</option>
			<option value="$4,100,000">$4,100,000</option>
			<option value="$4,200,000">$4,200,000</option>
			<option value="$4,300,000">$4,300,000</option>
			<option value="$4,400,000">$4,400,000</option>
			<option value="$4,500,000">$4,500,000</option>
			<option value="$4,600,000">$4,600,000</option>
			<option value="$4,700,000">$4,700,000</option>
			<option value="$4,800,000">$4,800,000</option>
			<option value="$4,900,000">$4,900,000</option>
			<option value="$5,000,000">$5,000,000</option>
			<option value="$5,100,000">$5,100,000</option>
			<option value="$5,200,000">$5,200,000</option>
			<option value="$5,300,000">$5,300,000</option>
			<option value="$5,400,000">$5,400,000</option>
			<option value="$5,500,000">$5,500,000</option>
			<option value="$5,600,000">$5,600,000</option>
			<option value="$5,700,000">$5,700,000</option>
			<option value="$5,800,000">$5,800,000</option>
			<option value="$5,900,000">$5,900,000</option>
			<option value="$6,000,000">$6,000,000</option>
			<option value="$7,000,000">$7,000,000</option>
			<option value="$8,000,000">$8,000,000</option>
			<option value="$9,000,000">$9,000,000</option>
			<option value="$10,000,000">$10,000,000</option>
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		<field type="select" name="desired-duration-of-policy" label="Desired duration of policy">
			<option selected="true" value="">Select One</option>
			<option value="10 Year">10 Year</option>
			<option value="15 Year">15 Year</option>
			<option value="20 Year">20 Year</option>
			<option value="30 Year">30 Year</option>
		</field>
		<field type="checkbox-group" name="high-risk-activities" label="Do you engage in any of the following sports or activities?">
			<option value="Scuba diving ">Scuba diving </option>
			<option value="Hot air ballooning ">Hot air ballooning </option>
			<option value="Mountain climbing">Mountain climbing</option>
			<option value="Motor/speedboat racing ">Motor/speedboat racing </option>
			<option value="Bungee jumping ">Bungee jumping </option>
			<option value="Hang gliding ">Hang gliding </option>
			<option value="Sky diving ">Sky diving </option>
			<option value="Rock climbing ">Rock climbing </option>
			<option value="Horse racing ">Horse racing </option>
			<option value="High diving ">High diving </option>
			<option value="Aircraft piloting">Aircraft piloting</option>
			<option value="Frequent international traveling">Frequent international traveling</option>
		</field>
		<field type="textarea" name="comments" placeholder="Please include any details or comments regarding this quote request" label="Comments"/>
	</fields>
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For the past eleven years, I have been with Shapiro insurance. When it comes to renewing policies, transferring insurance to new cars, or when we added my husband to the policy, Shapiro has always helped us and kept our best interests in mind. There is no other agency I would recommend in the Jacksonville area...and now that they have offices all throughout Florida, I can recommend them to friends and family across the state!

— Danielle S.

	9313 Old Kings Rd S, Jacksonville, Florida 32257
	800.563.5467
	info@insuresig.com