<META HTTP-EQUIV="Content-type" CONTENT="text/html; charset=UTF-8">

<form name="frm" method="post" action="https://www.teamdesk.net/secure/gateway.aspx?action=WebToRecord&amp;app=9365&amp;form=52131">

<input type="hidden" name="retURL" value="http://www.novarica.com"><table>

    <tr>

      <td nowrap class="caption">Company Name:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px"><input type="text" name="f_540932" maxlength="40" value="" style="width:100%"></div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">Headquarters:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px"><textarea name="f_540933" rows="5" cols="40" style="width:100%"></textarea></div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">Total Employees:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px"><input type="text" name="f_540934" style="width:100px" maxlength="" value="">&nbsp;</div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">Solution Name:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px"><input type="text" name="f_540936" maxlength="40" value="" style="width:100%"></div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">Solution URL:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px"><input type="text" name="f_540937" maxlength="255" value="" style="width:100%"></div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">Solution Primary Con...:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px"><textarea name="f_540938" rows="5" cols="40" style="width:100%"></textarea></div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">Year solution was la...:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px"><input type="text" name="f_540939" maxlength="40" value="" style="width:100%"></div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">Year solution was la...:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px"><input type="text" name="f_540940" maxlength="40" value="" style="width:100%"></div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">Primary Solution Category:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px">

          <div><input type="radio" id="f_540943_1" name="f_540943" value="Agent Portal with e-App Capabilities" checked>&nbsp;<label for="f_540943_1">Agent Portal with e-App Capabilities</label></div>

          <div><input type="radio" id="f_540943_2" name="f_540943" value="Agent Portal without e-App">&nbsp;<label for="f_540943_2">Agent Portal without e-App</label></div>

          <div><input type="radio" id="f_540943_3" name="f_540943" value="Billing System">&nbsp;<label for="f_540943_3">Billing System</label></div>

          <div><input type="radio" id="f_540943_4" name="f_540943" value="Business Intelligence: Reporting">&nbsp;<label for="f_540943_4">Business Intelligence: Reporting</label></div>

          <div><input type="radio" id="f_540943_5" name="f_540943" value="Business Intelligence: Repository">&nbsp;<label for="f_540943_5">Business Intelligence: Repository</label></div>

          <div><input type="radio" id="f_540943_6" name="f_540943" value="Business Intelligence: Repository and Reporting">&nbsp;<label for="f_540943_6">Business Intelligence: Repository and Reporting</label></div>

          <div><input type="radio" id="f_540943_7" name="f_540943" value="Business Process Management Platform">&nbsp;<label for="f_540943_7">Business Process Management Platform</label></div>

          <div><input type="radio" id="f_540943_8" name="f_540943" value="Business Rules Engine">&nbsp;<label for="f_540943_8">Business Rules Engine</label></div>

          <div><input type="radio" id="f_540943_9" name="f_540943" value="Claims, Integrated Workflow and Management">&nbsp;<label for="f_540943_9">Claims, Integrated Workflow and Management</label></div>

          <div><input type="radio" id="f_540943_10" name="f_540943" value="Claims, Specialized Tools">&nbsp;<label for="f_540943_10">Claims, Specialized Tools</label></div>

          <div><input type="radio" id="f_540943_11" name="f_540943" value="Commissions Management">&nbsp;<label for="f_540943_11">Commissions Management</label></div>

          <div><input type="radio" id="f_540943_12" name="f_540943" value="Common Calculation Engine">&nbsp;<label for="f_540943_12">Common Calculation Engine</label></div>

          <div><input type="radio" id="f_540943_13" name="f_540943" value="Consumer Portal With Online Sales">&nbsp;<label for="f_540943_13">Consumer Portal With Online Sales</label></div>

          <div><input type="radio" id="f_540943_14" name="f_540943" value="CRM - Contact Center Management">&nbsp;<label for="f_540943_14">CRM - Contact Center Management</label></div>

          <div><input type="radio" id="f_540943_15" name="f_540943" value="CRM - Customer Data Integration and Analytics">&nbsp;<label for="f_540943_15">CRM - Customer Data Integration and Analytics</label></div>

          <div><input type="radio" id="f_540943_16" name="f_540943" value="Customer Portal with Account Integration">&nbsp;<label for="f_540943_16">Customer Portal with Account Integration</label></div>

          <div><input type="radio" id="f_540943_17" name="f_540943" value="Document Creation/Authoring - any volume, any complexity">&nbsp;<label for="f_540943_17">Document Creation/Authoring - any volume, any complexity</label></div>

          <div><input type="radio" id="f_540943_18" name="f_540943" value="Document Creation/Authoring - hi volume, lo complexity">&nbsp;<label for="f_540943_18">Document Creation/Authoring - hi volume, lo complexity</label></div>

          <div><input type="radio" id="f_540943_19" name="f_540943" value="Document Creation/Authoring - lo volume, hi complexity">&nbsp;<label for="f_540943_19">Document Creation/Authoring - lo volume, hi complexity</label></div>

          <div><input type="radio" id="f_540943_20" name="f_540943" value="Document Repository/Workflow">&nbsp;<label for="f_540943_20">Document Repository/Workflow</label></div>

          <div><input type="radio" id="f_540943_21" name="f_540943" value="General Ledger/ERP">&nbsp;<label for="f_540943_21">General Ledger/ERP</label></div>

          <div><input type="radio" id="f_540943_22" name="f_540943" value="Illustrations">&nbsp;<label for="f_540943_22">Illustrations</label></div>

          <div><input type="radio" id="f_540943_23" name="f_540943" value="Policy Admin Class 1 Core (Issuance, Management, Reporting)">&nbsp;<label for="f_540943_23">Policy Admin Class 1 Core (Issuance, Management, Reporting)</label></div>

          <div><input type="radio" id="f_540943_24" name="f_540943" value="Policy Admin Class 2: Class 1 plus rating">&nbsp;<label for="f_540943_24">Policy Admin Class 2: Class 1 plus rating</label></div>

          <div><input type="radio" id="f_540943_25" name="f_540943" value="Policy Admin Class 3: Class 2 plus billing">&nbsp;<label for="f_540943_25">Policy Admin Class 3: Class 2 plus billing</label></div>

          <div><input type="radio" id="f_540943_26" name="f_540943" value="Policy Admin Class 4: Class 3 plus claims">&nbsp;<label for="f_540943_26">Policy Admin Class 4: Class 3 plus claims</label></div>

          <div><input type="radio" id="f_540943_27" name="f_540943" value="Policy Admin Class 5: Class 4 plus reinsurance management">&nbsp;<label for="f_540943_27">Policy Admin Class 5: Class 4 plus reinsurance management</label></div>

          <div><input type="radio" id="f_540943_28" name="f_540943" value="Policy Admin Class 6: Class 5 plus other capabilities">&nbsp;<label for="f_540943_28">Policy Admin Class 6: Class 5 plus other capabilities</label></div>

          <div><input type="radio" id="f_540943_29" name="f_540943" value="Predictive Analytics">&nbsp;<label for="f_540943_29">Predictive Analytics</label></div>

          <div><input type="radio" id="f_540943_30" name="f_540943" value="Product Modeling and Management">&nbsp;<label for="f_540943_30">Product Modeling and Management</label></div>

          <div><input type="radio" id="f_540943_31" name="f_540943" value="Rating Engine">&nbsp;<label for="f_540943_31">Rating Engine</label></div>

          <div><input type="radio" id="f_540943_32" name="f_540943" value="Reinsurance Management">&nbsp;<label for="f_540943_32">Reinsurance Management</label></div>

          <div><input type="radio" id="f_540943_33" name="f_540943" value="Sales Force Administration">&nbsp;<label for="f_540943_33">Sales Force Administration</label></div>

          <div><input type="radio" id="f_540943_34" name="f_540943" value="Underwriter Tools, Specialized">&nbsp;<label for="f_540943_34">Underwriter Tools, Specialized</label></div>

          <div><input type="radio" id="f_540943_35" name="f_540943" value="Underwriter Workflow, Integrated with Agent Portal and Rating">&nbsp;<label for="f_540943_35">Underwriter Workflow, Integrated with Agent Portal and Rating</label></div>

          <div><input type="radio" id="f_540943_36" name="f_540943" value="Underwriter Workflow, Internal">&nbsp;<label for="f_540943_36">Underwriter Workflow, Internal</label></div>

        </div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">Solution Secondary Category:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px">

          <div><input type="radio" id="f_540944_1" name="f_540944" value="Agent Portal with e-App Capabilities" checked>&nbsp;<label for="f_540944_1">Agent Portal with e-App Capabilities</label></div>

          <div><input type="radio" id="f_540944_2" name="f_540944" value="Agent Portal without e-App">&nbsp;<label for="f_540944_2">Agent Portal without e-App</label></div>

          <div><input type="radio" id="f_540944_3" name="f_540944" value="Billing System">&nbsp;<label for="f_540944_3">Billing System</label></div>

          <div><input type="radio" id="f_540944_4" name="f_540944" value="Business Intelligence: Reporting">&nbsp;<label for="f_540944_4">Business Intelligence: Reporting</label></div>

          <div><input type="radio" id="f_540944_5" name="f_540944" value="Business Intelligence: Repository">&nbsp;<label for="f_540944_5">Business Intelligence: Repository</label></div>

          <div><input type="radio" id="f_540944_6" name="f_540944" value="Business Intelligence: Repository and Reporting">&nbsp;<label for="f_540944_6">Business Intelligence: Repository and Reporting</label></div>

          <div><input type="radio" id="f_540944_7" name="f_540944" value="Business Process Management Platform">&nbsp;<label for="f_540944_7">Business Process Management Platform</label></div>

          <div><input type="radio" id="f_540944_8" name="f_540944" value="Business Rules Engine">&nbsp;<label for="f_540944_8">Business Rules Engine</label></div>

          <div><input type="radio" id="f_540944_9" name="f_540944" value="Claims, Integrated Workflow and Management">&nbsp;<label for="f_540944_9">Claims, Integrated Workflow and Management</label></div>

          <div><input type="radio" id="f_540944_10" name="f_540944" value="Claims, Specialized Tools">&nbsp;<label for="f_540944_10">Claims, Specialized Tools</label></div>

          <div><input type="radio" id="f_540944_11" name="f_540944" value="Commissions Management">&nbsp;<label for="f_540944_11">Commissions Management</label></div>

          <div><input type="radio" id="f_540944_12" name="f_540944" value="Common Calculation Engine">&nbsp;<label for="f_540944_12">Common Calculation Engine</label></div>

          <div><input type="radio" id="f_540944_13" name="f_540944" value="Consumer Portal With Online Sales">&nbsp;<label for="f_540944_13">Consumer Portal With Online Sales</label></div>

          <div><input type="radio" id="f_540944_14" name="f_540944" value="CRM - Contact Center Management">&nbsp;<label for="f_540944_14">CRM - Contact Center Management</label></div>

          <div><input type="radio" id="f_540944_15" name="f_540944" value="CRM - Customer Data Integration and Analytics">&nbsp;<label for="f_540944_15">CRM - Customer Data Integration and Analytics</label></div>

          <div><input type="radio" id="f_540944_16" name="f_540944" value="Customer Portal with Account Integration">&nbsp;<label for="f_540944_16">Customer Portal with Account Integration</label></div>

          <div><input type="radio" id="f_540944_17" name="f_540944" value="Document Creation/Authoring - any volume, any complexity">&nbsp;<label for="f_540944_17">Document Creation/Authoring - any volume, any complexity</label></div>

          <div><input type="radio" id="f_540944_18" name="f_540944" value="Document Creation/Authoring - hi volume, lo complexity">&nbsp;<label for="f_540944_18">Document Creation/Authoring - hi volume, lo complexity</label></div>

          <div><input type="radio" id="f_540944_19" name="f_540944" value="Document Creation/Authoring - lo volume, hi complexity">&nbsp;<label for="f_540944_19">Document Creation/Authoring - lo volume, hi complexity</label></div>

          <div><input type="radio" id="f_540944_20" name="f_540944" value="Document Repository/Workflow">&nbsp;<label for="f_540944_20">Document Repository/Workflow</label></div>

          <div><input type="radio" id="f_540944_21" name="f_540944" value="General Ledger/ERP">&nbsp;<label for="f_540944_21">General Ledger/ERP</label></div>

          <div><input type="radio" id="f_540944_22" name="f_540944" value="Illustrations">&nbsp;<label for="f_540944_22">Illustrations</label></div>

          <div><input type="radio" id="f_540944_23" name="f_540944" value="Policy Admin Class 1 Core (Issuance, Management, Reporting)">&nbsp;<label for="f_540944_23">Policy Admin Class 1 Core (Issuance, Management, Reporting)</label></div>

          <div><input type="radio" id="f_540944_24" name="f_540944" value="Policy Admin Class 2: Class 1 plus rating">&nbsp;<label for="f_540944_24">Policy Admin Class 2: Class 1 plus rating</label></div>

          <div><input type="radio" id="f_540944_25" name="f_540944" value="Policy Admin Class 3: Class 2 plus billing">&nbsp;<label for="f_540944_25">Policy Admin Class 3: Class 2 plus billing</label></div>

          <div><input type="radio" id="f_540944_26" name="f_540944" value="Policy Admin Class 4: Class 3 plus claims">&nbsp;<label for="f_540944_26">Policy Admin Class 4: Class 3 plus claims</label></div>

          <div><input type="radio" id="f_540944_27" name="f_540944" value="Policy Admin Class 5: Class 4 plus reinsurance management">&nbsp;<label for="f_540944_27">Policy Admin Class 5: Class 4 plus reinsurance management</label></div>

          <div><input type="radio" id="f_540944_28" name="f_540944" value="Policy Admin Class 6: Class 5 plus other capabilities">&nbsp;<label for="f_540944_28">Policy Admin Class 6: Class 5 plus other capabilities</label></div>

          <div><input type="radio" id="f_540944_29" name="f_540944" value="Predictive Analytics">&nbsp;<label for="f_540944_29">Predictive Analytics</label></div>

          <div><input type="radio" id="f_540944_30" name="f_540944" value="Product Modeling and Management">&nbsp;<label for="f_540944_30">Product Modeling and Management</label></div>

          <div><input type="radio" id="f_540944_31" name="f_540944" value="Rating Engine">&nbsp;<label for="f_540944_31">Rating Engine</label></div>

          <div><input type="radio" id="f_540944_32" name="f_540944" value="Reinsurance Management">&nbsp;<label for="f_540944_32">Reinsurance Management</label></div>

          <div><input type="radio" id="f_540944_33" name="f_540944" value="Sales Force Administration">&nbsp;<label for="f_540944_33">Sales Force Administration</label></div>

          <div><input type="radio" id="f_540944_34" name="f_540944" value="Underwriter Tools, Specialized">&nbsp;<label for="f_540944_34">Underwriter Tools, Specialized</label></div>

          <div><input type="radio" id="f_540944_35" name="f_540944" value="Underwriter Workflow, Integrated with Agent Portal and Rating">&nbsp;<label for="f_540944_35">Underwriter Workflow, Integrated with Agent Portal and Rating</label></div>

          <div><input type="radio" id="f_540944_36" name="f_540944" value="Underwriter Workflow, Internal">&nbsp;<label for="f_540944_36">Underwriter Workflow, Internal</label></div>

        </div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">Additional Description:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px"><input type="text" name="f_540945" maxlength="40" value="" style="width:100%"></div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">Top 5 Core Functions:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px"><input type="text" name="f_540946" maxlength="40" value="" style="width:100%"></div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">Top 5 Differentiators:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px"><input type="text" name="f_540947" maxlength="40" value="" style="width:100%"></div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">ISO Rate/Form Support:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px"><input type="text" name="f_540948" maxlength="40" value="" style="width:100%"></div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">Personal Auto:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px">

          <div><input type="radio" id="f_540949_1" name="f_540949" value="Not currently supported" checked>&nbsp;<label for="f_540949_1">Not currently supported</label></div>

          <div><input type="radio" id="f_540949_2" name="f_540949" value="Solution is designed to support, but no clients">&nbsp;<label for="f_540949_2">Solution is designed to support, but no clients</label></div>

          <div><input type="radio" id="f_540949_3" name="f_540949" value="Clients currently in implementation for this line/product">&nbsp;<label for="f_540949_3">Clients currently in implementation for this line/product</label></div>

          <div><input type="radio" id="f_540949_4" name="f_540949" value="Live clients offering product in at least one US state">&nbsp;<label for="f_540949_4">Live clients offering product in at least one US state</label></div>

          <div><input type="radio" id="f_540949_5" name="f_540949" value="Live clients offering product in several US states">&nbsp;<label for="f_540949_5">Live clients offering product in several US states</label></div>

          <div><input type="radio" id="f_540949_6" name="f_540949" value="Live clients offering product in all 50 states">&nbsp;<label for="f_540949_6">Live clients offering product in all 50 states</label></div>

        </div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">Other P/C:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px">

          <div><input type="radio" id="f_540950_1" name="f_540950" value="Not currently supported" checked>&nbsp;<label for="f_540950_1">Not currently supported</label></div>

          <div><input type="radio" id="f_540950_2" name="f_540950" value="Solution is designed to support, but no clients">&nbsp;<label for="f_540950_2">Solution is designed to support, but no clients</label></div>

          <div><input type="radio" id="f_540950_3" name="f_540950" value="Clients currently in implementation for this line/product">&nbsp;<label for="f_540950_3">Clients currently in implementation for this line/product</label></div>

          <div><input type="radio" id="f_540950_4" name="f_540950" value="Live clients offering product in at least one US state">&nbsp;<label for="f_540950_4">Live clients offering product in at least one US state</label></div>

          <div><input type="radio" id="f_540950_5" name="f_540950" value="Live clients offering product in several US states">&nbsp;<label for="f_540950_5">Live clients offering product in several US states</label></div>

          <div><input type="radio" id="f_540950_6" name="f_540950" value="Live clients offering product in all 50 states">&nbsp;<label for="f_540950_6">Live clients offering product in all 50 states</label></div>

        </div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">Individual Life:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px">

          <div><input type="radio" id="f_540951_1" name="f_540951" value="Not currently supported" checked>&nbsp;<label for="f_540951_1">Not currently supported</label></div>

          <div><input type="radio" id="f_540951_2" name="f_540951" value="Solution is designed to support, but no clients">&nbsp;<label for="f_540951_2">Solution is designed to support, but no clients</label></div>

          <div><input type="radio" id="f_540951_3" name="f_540951" value="Clients currently in implementation for this line/product">&nbsp;<label for="f_540951_3">Clients currently in implementation for this line/product</label></div>

          <div><input type="radio" id="f_540951_4" name="f_540951" value="Live clients offering product in at least one US state">&nbsp;<label for="f_540951_4">Live clients offering product in at least one US state</label></div>

          <div><input type="radio" id="f_540951_5" name="f_540951" value="Live clients offering product in several US states">&nbsp;<label for="f_540951_5">Live clients offering product in several US states</label></div>

          <div><input type="radio" id="f_540951_6" name="f_540951" value="Live clients offering product in all 50 states">&nbsp;<label for="f_540951_6">Live clients offering product in all 50 states</label></div>

        </div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">Group Life:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px">

          <div><input type="radio" id="f_540952_1" name="f_540952" value="Not currently supported" checked>&nbsp;<label for="f_540952_1">Not currently supported</label></div>

          <div><input type="radio" id="f_540952_2" name="f_540952" value="Solution is designed to support, but no clients">&nbsp;<label for="f_540952_2">Solution is designed to support, but no clients</label></div>

          <div><input type="radio" id="f_540952_3" name="f_540952" value="Clients currently in implementation for this line/product">&nbsp;<label for="f_540952_3">Clients currently in implementation for this line/product</label></div>

          <div><input type="radio" id="f_540952_4" name="f_540952" value="Live clients offering product in at least one US state">&nbsp;<label for="f_540952_4">Live clients offering product in at least one US state</label></div>

          <div><input type="radio" id="f_540952_5" name="f_540952" value="Live clients offering product in several US states">&nbsp;<label for="f_540952_5">Live clients offering product in several US states</label></div>

          <div><input type="radio" id="f_540952_6" name="f_540952" value="Live clients offering product in all 50 states">&nbsp;<label for="f_540952_6">Live clients offering product in all 50 states</label></div>

        </div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">Fixed Annuities:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px">

          <div><input type="radio" id="f_540953_1" name="f_540953" value="Not currently supported" checked>&nbsp;<label for="f_540953_1">Not currently supported</label></div>

          <div><input type="radio" id="f_540953_2" name="f_540953" value="Solution is designed to support, but no clients">&nbsp;<label for="f_540953_2">Solution is designed to support, but no clients</label></div>

          <div><input type="radio" id="f_540953_3" name="f_540953" value="Clients currently in implementation for this line/product">&nbsp;<label for="f_540953_3">Clients currently in implementation for this line/product</label></div>

          <div><input type="radio" id="f_540953_4" name="f_540953" value="Live clients offering product in at least one US state">&nbsp;<label for="f_540953_4">Live clients offering product in at least one US state</label></div>

          <div><input type="radio" id="f_540953_5" name="f_540953" value="Live clients offering product in several US states">&nbsp;<label for="f_540953_5">Live clients offering product in several US states</label></div>

          <div><input type="radio" id="f_540953_6" name="f_540953" value="Live clients offering product in all 50 states">&nbsp;<label for="f_540953_6">Live clients offering product in all 50 states</label></div>

        </div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">Variable Annuities:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px">

          <div><input type="radio" id="f_540954_1" name="f_540954" value="Not currently supported" checked>&nbsp;<label for="f_540954_1">Not currently supported</label></div>

          <div><input type="radio" id="f_540954_2" name="f_540954" value="Solution is designed to support, but no clients">&nbsp;<label for="f_540954_2">Solution is designed to support, but no clients</label></div>

          <div><input type="radio" id="f_540954_3" name="f_540954" value="Clients currently in implementation for this line/product">&nbsp;<label for="f_540954_3">Clients currently in implementation for this line/product</label></div>

          <div><input type="radio" id="f_540954_4" name="f_540954" value="Live clients offering product in at least one US state">&nbsp;<label for="f_540954_4">Live clients offering product in at least one US state</label></div>

          <div><input type="radio" id="f_540954_5" name="f_540954" value="Live clients offering product in several US states">&nbsp;<label for="f_540954_5">Live clients offering product in several US states</label></div>

          <div><input type="radio" id="f_540954_6" name="f_540954" value="Live clients offering product in all 50 states">&nbsp;<label for="f_540954_6">Live clients offering product in all 50 states</label></div>

        </div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">Disability:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px">

          <div><input type="radio" id="f_540955_1" name="f_540955" value="Not currently supported" checked>&nbsp;<label for="f_540955_1">Not currently supported</label></div>

          <div><input type="radio" id="f_540955_2" name="f_540955" value="Solution is designed to support, but no clients">&nbsp;<label for="f_540955_2">Solution is designed to support, but no clients</label></div>

          <div><input type="radio" id="f_540955_3" name="f_540955" value="Clients currently in implementation for this line/product">&nbsp;<label for="f_540955_3">Clients currently in implementation for this line/product</label></div>

          <div><input type="radio" id="f_540955_4" name="f_540955" value="Live clients offering product in at least one US state">&nbsp;<label for="f_540955_4">Live clients offering product in at least one US state</label></div>

          <div><input type="radio" id="f_540955_5" name="f_540955" value="Live clients offering product in several US states">&nbsp;<label for="f_540955_5">Live clients offering product in several US states</label></div>

          <div><input type="radio" id="f_540955_6" name="f_540955" value="Live clients offering product in all 50 states">&nbsp;<label for="f_540955_6">Live clients offering product in all 50 states</label></div>

        </div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">LTC:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px">

          <div><input type="radio" id="f_540956_1" name="f_540956" value="Not currently supported" checked>&nbsp;<label for="f_540956_1">Not currently supported</label></div>

          <div><input type="radio" id="f_540956_2" name="f_540956" value="Solution is designed to support, but no clients">&nbsp;<label for="f_540956_2">Solution is designed to support, but no clients</label></div>

          <div><input type="radio" id="f_540956_3" name="f_540956" value="Clients currently in implementation for this line/product">&nbsp;<label for="f_540956_3">Clients currently in implementation for this line/product</label></div>

          <div><input type="radio" id="f_540956_4" name="f_540956" value="Live clients offering product in at least one US state">&nbsp;<label for="f_540956_4">Live clients offering product in at least one US state</label></div>

          <div><input type="radio" id="f_540956_5" name="f_540956" value="Live clients offering product in several US states">&nbsp;<label for="f_540956_5">Live clients offering product in several US states</label></div>

          <div><input type="radio" id="f_540956_6" name="f_540956" value="Live clients offering product in all 50 states">&nbsp;<label for="f_540956_6">Live clients offering product in all 50 states</label></div>

        </div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">Individual Health:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px">

          <div><input type="checkbox" id="f_540957_1" name="f_540957" value="Not currently supported">&nbsp;<label for="f_540957_1">Not currently supported</label></div>

          <div><input type="checkbox" id="f_540957_2" name="f_540957" value="Solution is designed to support, but no clients">&nbsp;<label for="f_540957_2">Solution is designed to support, but no clients</label></div>

          <div><input type="checkbox" id="f_540957_3" name="f_540957" value="Clients currently in implementation for this line/product">&nbsp;<label for="f_540957_3">Clients currently in implementation for this line/product</label></div>

          <div><input type="checkbox" id="f_540957_4" name="f_540957" value="Live clients offering product in at least one US state">&nbsp;<label for="f_540957_4">Live clients offering product in at least one US state</label></div>

          <div><input type="checkbox" id="f_540957_5" name="f_540957" value="Live clients offering product in several US states">&nbsp;<label for="f_540957_5">Live clients offering product in several US states</label></div>

          <div><input type="checkbox" id="f_540957_6" name="f_540957" value="Live clients offering product in all 50 states">&nbsp;<label for="f_540957_6">Live clients offering product in all 50 states</label></div>

        </div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">Group Health:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px">

          <div><input type="radio" id="f_540958_1" name="f_540958" value="Not currently supported" checked>&nbsp;<label for="f_540958_1">Not currently supported</label></div>

          <div><input type="radio" id="f_540958_2" name="f_540958" value="Solution is designed to support, but no clients">&nbsp;<label for="f_540958_2">Solution is designed to support, but no clients</label></div>

          <div><input type="radio" id="f_540958_3" name="f_540958" value="Clients currently in implementation for this line/product">&nbsp;<label for="f_540958_3">Clients currently in implementation for this line/product</label></div>

          <div><input type="radio" id="f_540958_4" name="f_540958" value="Live clients offering product in at least one US state">&nbsp;<label for="f_540958_4">Live clients offering product in at least one US state</label></div>

          <div><input type="radio" id="f_540958_5" name="f_540958" value="Live clients offering product in several US states">&nbsp;<label for="f_540958_5">Live clients offering product in several US states</label></div>

          <div><input type="radio" id="f_540958_6" name="f_540958" value="Live clients offering product in all 50 states">&nbsp;<label for="f_540958_6">Live clients offering product in all 50 states</label></div>

        </div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">Other L/A/H:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px">

          <div><input type="radio" id="f_540959_1" name="f_540959" value="Not currently supported" checked>&nbsp;<label for="f_540959_1">Not currently supported</label></div>

          <div><input type="radio" id="f_540959_2" name="f_540959" value="Solution is designed to support, but no clients">&nbsp;<label for="f_540959_2">Solution is designed to support, but no clients</label></div>

          <div><input type="radio" id="f_540959_3" name="f_540959" value="Clients currently in implementation for this line/product">&nbsp;<label for="f_540959_3">Clients currently in implementation for this line/product</label></div>

          <div><input type="radio" id="f_540959_4" name="f_540959" value="Live clients offering product in at least one US state">&nbsp;<label for="f_540959_4">Live clients offering product in at least one US state</label></div>

          <div><input type="radio" id="f_540959_5" name="f_540959" value="Live clients offering product in several US states">&nbsp;<label for="f_540959_5">Live clients offering product in several US states</label></div>

          <div><input type="radio" id="f_540959_6" name="f_540959" value="Live clients offering product in all 50 states">&nbsp;<label for="f_540959_6">Live clients offering product in all 50 states</label></div>

        </div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">Platform:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px">

          <div><input type="radio" id="f_540960_1" name="f_540960" value="OS/390 required for core" checked>&nbsp;<label for="f_540960_1">OS/390 required for core</label></div>

          <div><input type="radio" id="f_540960_2" name="f_540960" value="OS/400 required for core">&nbsp;<label for="f_540960_2">OS/400 required for core</label></div>

          <div><input type="radio" id="f_540960_3" name="f_540960" value="Unix/Linux required for core">&nbsp;<label for="f_540960_3">Unix/Linux required for core</label></div>

          <div><input type="radio" id="f_540960_4" name="f_540960" value="Windows required for core">&nbsp;<label for="f_540960_4">Windows required for core</label></div>

          <div><input type="radio" id="f_540960_5" name="f_540960" value="Unix/Linux or OS/390 required">&nbsp;<label for="f_540960_5">Unix/Linux or OS/390 required</label></div>

          <div><input type="radio" id="f_540960_6" name="f_540960" value="Unix/Linux or Windows required">&nbsp;<label for="f_540960_6">Unix/Linux or Windows required</label></div>

          <div><input type="radio" id="f_540960_7" name="f_540960" value="Can run on any platform">&nbsp;<label for="f_540960_7">Can run on any platform</label></div>

        </div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">Database:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px">

          <div><input type="radio" id="f_540961_1" name="f_540961" value="DB2/UDB required" checked>&nbsp;<label for="f_540961_1">DB2/UDB required</label></div>

          <div><input type="radio" id="f_540961_2" name="f_540961" value="Oracle required">&nbsp;<label for="f_540961_2">Oracle required</label></div>

          <div><input type="radio" id="f_540961_3" name="f_540961" value="MS-SQL required">&nbsp;<label for="f_540961_3">MS-SQL required</label></div>

          <div><input type="radio" id="f_540961_4" name="f_540961" value="Other database required">&nbsp;<label for="f_540961_4">Other database required</label></div>

          <div><input type="radio" id="f_540961_5" name="f_540961" value="Oracle or DB2/UDB required">&nbsp;<label for="f_540961_5">Oracle or DB2/UDB required</label></div>

          <div><input type="radio" id="f_540961_6" name="f_540961" value="Can run on any database">&nbsp;<label for="f_540961_6">Can run on any database</label></div>

        </div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">UI:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px">

          <div><input type="radio" id="f_540962_1" name="f_540962" value="Green screen/Terminal" checked>&nbsp;<label for="f_540962_1">Green screen/Terminal</label></div>

          <div><input type="radio" id="f_540962_2" name="f_540962" value="Windows Client">&nbsp;<label for="f_540962_2">Windows Client</label></div>

          <div><input type="radio" id="f_540962_3" name="f_540962" value="Windows Client for Admin, Browser for Users">&nbsp;<label for="f_540962_3">Windows Client for Admin, Browser for Users</label></div>

          <div><input type="radio" id="f_540962_4" name="f_540962" value="Browser-based for all functions">&nbsp;<label for="f_540962_4">Browser-based for all functions</label></div>

        </div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">Programming Language:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px">

          <div><input type="radio" id="f_540963_1" name="f_540963" value="Java" checked>&nbsp;<label for="f_540963_1">Java</label></div>

          <div><input type="radio" id="f_540963_2" name="f_540963" value=".NET/C#">&nbsp;<label for="f_540963_2">.NET/C#</label></div>

          <div><input type="radio" id="f_540963_3" name="f_540963" value="C++">&nbsp;<label for="f_540963_3">C++</label></div>

          <div><input type="radio" id="f_540963_4" name="f_540963" value="PL/SQL">&nbsp;<label for="f_540963_4">PL/SQL</label></div>

          <div><input type="radio" id="f_540963_5" name="f_540963" value="VB">&nbsp;<label for="f_540963_5">VB</label></div>

          <div><input type="radio" id="f_540963_6" name="f_540963" value="COBOL">&nbsp;<label for="f_540963_6">COBOL</label></div>

          <div><input type="radio" id="f_540963_7" name="f_540963" value="RPG">&nbsp;<label for="f_540963_7">RPG</label></div>

          <div><input type="radio" id="f_540963_8" name="f_540963" value="Other">&nbsp;<label for="f_540963_8">Other</label></div>

        </div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">ACORD XML Messaging:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px"><input type="text" name="f_540964" maxlength="40" value="" style="width:100%"></div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">Support headcount:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px"><input type="text" name="f_540965" style="width:100px" maxlength="" value="">&nbsp;</div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">Customer-facing support headcount:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px"><input type="text" name="f_540966" style="width:100px" maxlength="" value="">&nbsp;</div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">Average years experience:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px"><input type="text" name="f_540967" style="width:100px" maxlength="" value="">&nbsp;</div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">Dedicated support or common pool:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px"><input type="text" name="f_540968" maxlength="40" value="" style="width:100%"></div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">P/C Personal Over $1 Bn:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px"><input type="text" name="f_540969" style="width:100px" maxlength="" value="">&nbsp;</div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">P/C Personal Under $1 Bn:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px"><input type="text" name="f_540970" style="width:100px" maxlength="" value="">&nbsp;</div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">P/C Commercial Over $1 Bn:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px"><input type="text" name="f_540971" style="width:100px" maxlength="" value="">&nbsp;</div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">P/C Commercial Under $1 Bn:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px"><input type="text" name="f_540972" style="width:100px" maxlength="" value="">&nbsp;</div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">P/C MGAs:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px"><input type="text" name="f_540973" style="width:100px" maxlength="" value="">&nbsp;</div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">P/C Reinsurers:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px"><input type="text" name="f_540974" style="width:100px" maxlength="" value="">&nbsp;</div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">Life/Annuity Over $1 Bn:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px"><input type="text" name="f_540975" style="width:100px" maxlength="" value="">&nbsp;</div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">Life/Annuity Under $1Bn:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px"><input type="text" name="f_540976" style="width:100px" maxlength="" value="">&nbsp;</div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">Life/Annuity MGAs/Wholesalers:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px"><input type="text" name="f_540977" style="width:100px" maxlength="" value="">&nbsp;</div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">Health Insurers Over $1 Bn:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px"><input type="text" name="f_540978" style="width:100px" maxlength="" value="">&nbsp;</div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">Health Insurers Under $1 Bn:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px"><input type="text" name="f_540979" style="width:100px" maxlength="" value="">&nbsp;</div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">L/A/H Reinsurers:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px"><input type="text" name="f_540980" style="width:100px" maxlength="" value="">&nbsp;</div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">Total Production Base:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px"><input type="text" name="f_540981" style="width:100px" maxlength="" value="">&nbsp;</div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">% Using Newest Release:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px"><input type="text" name="f_540982" style="width:100px" maxlength="" value="">&nbsp;%</div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">% Using Release Over 3 Years Old:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px"><input type="text" name="f_540983" style="width:100px" maxlength="" value="">&nbsp;%</div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">Average Time From Signing To Limited Go-Live:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px">

          <div><input type="radio" id="f_540985_1" name="f_540985" value="30 days or less" checked>&nbsp;<label for="f_540985_1">30 days or less</label></div>

          <div><input type="radio" id="f_540985_2" name="f_540985" value="90 days or less">&nbsp;<label for="f_540985_2">90 days or less</label></div>

          <div><input type="radio" id="f_540985_3" name="f_540985" value="180 days or less">&nbsp;<label for="f_540985_3">180 days or less</label></div>

          <div><input type="radio" id="f_540985_4" name="f_540985" value="9 months or less">&nbsp;<label for="f_540985_4">9 months or less</label></div>

          <div><input type="radio" id="f_540985_5" name="f_540985" value="12 months or less">&nbsp;<label for="f_540985_5">12 months or less</label></div>

          <div><input type="radio" id="f_540985_6" name="f_540985" value="18 months or less">&nbsp;<label for="f_540985_6">18 months or less</label></div>

          <div><input type="radio" id="f_540985_7" name="f_540985" value="24 months or less">&nbsp;<label for="f_540985_7">24 months or less</label></div>

          <div><input type="radio" id="f_540985_8" name="f_540985" value="More than 24 months">&nbsp;<label for="f_540985_8">More than 24 months</label></div>

        </div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">Average Time From Limited Go-Live to Full Deployme:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px">

          <div><input type="radio" id="f_540986_1" name="f_540986" value="30 days or less" checked>&nbsp;<label for="f_540986_1">30 days or less</label></div>

          <div><input type="radio" id="f_540986_2" name="f_540986" value="90 days or less">&nbsp;<label for="f_540986_2">90 days or less</label></div>

          <div><input type="radio" id="f_540986_3" name="f_540986" value="180 days or less">&nbsp;<label for="f_540986_3">180 days or less</label></div>

          <div><input type="radio" id="f_540986_4" name="f_540986" value="9 months or less">&nbsp;<label for="f_540986_4">9 months or less</label></div>

          <div><input type="radio" id="f_540986_5" name="f_540986" value="12 months or less">&nbsp;<label for="f_540986_5">12 months or less</label></div>

          <div><input type="radio" id="f_540986_6" name="f_540986" value="18 months or less">&nbsp;<label for="f_540986_6">18 months or less</label></div>

          <div><input type="radio" id="f_540986_7" name="f_540986" value="24 months or less">&nbsp;<label for="f_540986_7">24 months or less</label></div>

          <div><input type="radio" id="f_540986_8" name="f_540986" value="More than 24 months">&nbsp;<label for="f_540986_8">More than 24 months</label></div>

        </div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">Approximate Total Cost for Full Deployment:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px">

          <div><input type="radio" id="f_540987_1" name="f_540987" value="Under $100,000" checked>&nbsp;<label for="f_540987_1">Under $100,000</label></div>

          <div><input type="radio" id="f_540987_2" name="f_540987" value="$100,000-$500,000">&nbsp;<label for="f_540987_2">$100,000-$500,000</label></div>

          <div><input type="radio" id="f_540987_3" name="f_540987" value="$500,000-$1,000,000">&nbsp;<label for="f_540987_3">$500,000-$1,000,000</label></div>

          <div><input type="radio" id="f_540987_4" name="f_540987" value="$1,000,000 or more">&nbsp;<label for="f_540987_4">$1,000,000 or more</label></div>

        </div>

      </td>

    </tr>

    <tr>

      <td nowrap class="caption">Annual Revenue:</td>

      <td colspan="4" width="100%" class="editvalue" valign="top">

        <div style="padding-right:4px">

          <div><input type="radio" id="f_540988_1" name="f_540988" value="Under $5 million" checked>&nbsp;<label for="f_540988_1">Under $5 million</label></div>

          <div><input type="radio" id="f_540988_2" name="f_540988" value="Between $5 million and $25 million">&nbsp;<label for="f_540988_2">Between $5 million and $25 million</label></div>

          <div><input type="radio" id="f_540988_3" name="f_540988" value="Between $25 million and $100 million">&nbsp;<label for="f_540988_3">Between $25 million and $100 million</label></div>

          <div><input type="radio" id="f_540988_4" name="f_540988" value="Over $100 million">&nbsp;<label for="f_540988_4">Over $100 million</label></div>

        </div>

      </td>

    </tr>

    <tr>

      <td colspan="5" align="center"><input type="submit"></td>

    </tr>

  </table>

</form>