Driver Information
Driver Name:		"> * Driver # 1 "> Driver # 2 "> Driver # 3
Operator Number:		"> * Driver # 1 "> Driver # 2 "> Driver # 3
Date of Birth:		"> * Driver # 1 "> Driver # 2 "> Driver # 3
Sex:		> Male > Female    * Driver #1 > Male > Female    Driver #2 > Male > Female    Driver #3
Marital Status:		>Select a Marital Status >Single >Married >Divorced >Widowed * Driver #1 >Select a Marital Status >Single >Married >Divorced >Widowed Driver #2 >Select a Marital Status >Single >Married >Divorced >Widowed Driver #3
Traffic Violations:		> Yes > No   * Driver #1 > Yes > No   Driver #2 > Yes > No   Driver #3
If yes, please explain:
Currently Insured:		> Yes > No   * Driver #1 > Yes > No   Driver #2 > Yes > No   Driver #3
Current Carrier:		">
* Homeowner:		> Yes > No

Vehicle Information
Year/Make/Model:	"> * Car #1 "> Car #2 "> Car #3
* Garaging Zip:	">
* Tort Option:	> Full > Limited
* Liability Limits:	>Select a Limit >$15,000/$30,000 >$25,000/$50,000 >$50,000/$100,000 >$100,000/$300,000 >$250,000/$500,000 >$500,000/$1,000,000
* First Party Benefits:	>Select a Benefit >$5,000 >$10,000 >$25,000 >$50,000 >$100,000
* Work Loss:	>Select a Work Loss >None >$1,000 Monthly / $5,000 Total >$1,000 Monthly / $15,000 Total >$1,500 Monthly / $25,000 Total >$2,500 Monthly / $50,000 Total
* Funeral Expense:	>Select an Expense >None >$1,500 >$2,500
* Accidental Death:	>Select an Amount >None >$5,000 >$10,000 >$15,000 >$25,000
* Extraordinary Medical Benefits:	>Select a Benefit >None >$100,000 >$300,000 >$500,000 >$1,000,000
* Uninsured Motorist:	>Select an Amount >$15,000/$30,000 >$25,000/$50,000 >$50,000/$100,000 >$100,000/$300,000 >$250,000/$500,000 >$500,000/$1,000,000
* Underinsured Motorist:	>Select an Amount >$15,000/$30,000 >$25,000/$50,000 >$50,000/$100,000 >$100,000/$300,000 >$250,000/$500,000 >$500,000/$1,000,000
Comprehensive Deductible:	>Select a Deductible >None >$50 >$100 >$250 >$500 >$1,000 >$5,000 * Car #1 >Select a Deductible >None >$50 >$100 >$250 >$500 >$1,000 >$5,000 Car #2 >Select a Deductible >None >$50 >$100 >$250 >$500 >$1,000 >$5,000 Car #3
Collision Deductible:	>Select a Deductible >None >$50 >$100 >$250 >$500 >$1,000 >$5,000 * Car #1 >Select a Deductible >None >$50 >$100 >$250 >$500 >$1,000 >$5,000 Car #2 >Select a Deductible >None >$50 >$100 >$250 >$500 >$1,000 >$5,000 Car #3
Rental Reimbursement:	>Select a Reimbursement >None >$15 >$20 >$25 >$30 >$50 * Car #1 >Select a Reimbursement >None >$15 >$20 >$25 >$30 >$50 Car #2 >Select a Reimbursement >None >$15 >$20 >$25 >$30 >$50 Car #3
Towing:	>Select an Amount >None >$15 >$20 >$25 >$30 >$50 >$75 * Car #1 >Select an Amount >None >$15 >$20 >$25 >$30 >$50 >$75 Car #2 >Select an Amount >None >$15 >$20 >$25 >$30 >$50 >$75 Car #3
Use:	>Select Use >Pleasure >To / From Work >Business * Car #1 >Select Use >Pleasure >To / From Work >Business Car #2 >Select Use >Pleasure >To / From Work >Business Car #3
Anti-theft:	>Select a Device >None >Alarm / Active >Passive Disabling Device >Vehicle Recovery System >VIN etching * Car #1 >Select a Device >None >Alarm / Active >Passive Disabling Device >Vehicle Recovery System >VIN etching Car #2 >Select a Device >None >Alarm / Active >Passive Disabling Device >Vehicle Recovery System >VIN etching Car #3
Anti-Lock Brakes:	> Yes > No    * Car #1 > Yes > No    Car #2 > Yes > No    Car #3
Passive Restraint:	>Select a Restraint >None >Passive Seat Belts >Driver Air Bag >Dual Air Bags * Car #1 > >Select a Restraint >None >Passive Seat Belts >Driver Air Bag >Dual Air Bags Car #2 >Select a Restraint >None >Passive Seat Belts >Driver Air Bag >Dual Air Bags Car #3
Miles to Work:	">* Car #1 "> Car #2 "> Car #3
Annual Mileage:	"> Car #1 "> Car #2 "> Car #3
* - Denotes Required Field

<% End Sub %> <% If Request.ServerVariables("REQUEST_METHOD") = "POST" Then strname = Request.Form("name") stremail = Request.Form("email") strtelephone = Request.Form("telephone") strfax = Request.Form("fax") straddress = Request.Form("address") strzipcode = Request.Form("zipcode") strbesttimetocall = Request.Form("besttimetocall") strdrivername1 = Request.Form("drivername1") strdrivername2 = Request.Form("drivername2") strdrivername3 = Request.Form("drivername3") stroperator1 = Request.Form("operator1") stroperator2 = Request.Form("operator2") stroperator3 = Request.Form("operator3") strdateofbirth1 = Request.Form("dateofbirth1") strdateofbirth2 = Request.Form("dateofbirth2") strdateofbirth3 = Request.Form("dateofbirth3") strsex1 = Request.Form("sex1") strsex2 = Request.Form("sex2") strsex3 = Request.Form("sex3") strmaritalstatus1 = Request.Form("maritalstatus1") strmaritalstatus2 = Request.Form("maritalstatus2") strmaritalstatus3 = Request.Form("maritalstatus3") strtrafficviolations1 = Request.Form("trafficviolations1") strtrafficviolations2 = Request.Form("trafficviolations2") strtrafficviolations3 = Request.Form("trafficviolations3") strviolationexplanation = Request.Form("violationexplanation") strcurrentlyinsured1 = Request.Form("currentlyinsured1") strcurrentlyinsured2 = Request.Form("currentlyinsured2") strcurrentlyinsured3 = Request.Form("currentlyinsured3") strcurrentcarrier = Request.Form("currentcarrier") strhomeowner = Request.Form("homeowner") stryearmakemodel1 = Request.Form("yearmakemodel1") stryearmakemodel2 = Request.Form("yearmakemodel2") stryearmakemodel3 = Request.Form("yearmakemodel3") strgaragingzip = Request.Form("garagingzip") strtort = Request.Form("tort") strliabilitylimits = Request.Form("liabilitylimits") strfirstpartybenefits = Request.Form("firstpartybenefits") strworkloss = Request.Form("workloss") strfuneralexpense = Request.Form("funeralexpense") straccidentaldeath = Request.Form("accidentaldeath") strextraordinarymedicalbenefits = Request.Form("extraordinarymedicalbenefits") struninsuredmotorist = Request.Form("uninsuredmotorist") strunderinsuredmotorist = Request.Form("underinsuredmotorist") strcomprehensivedeductible1 = Request.Form("comprehensivedeductible1") strcomprehensivedeductible2 = Request.Form("comprehensivedeductible2") strcomprehensivedeductible3 = Request.Form("comprehensivedeductible3") strcollisiondeductible1 = Request.Form("collisiondeductible1") strcollisiondeductible2 = Request.Form("collisiondeductible2") strcollisiondeductible3 = Request.Form("collisiondeductible3") strrentalreimbursement1 = Request.Form("rentalreimbursement1") strrentalreimbursement2 = Request.Form("rentalreimbursement2") strrentalreimbursement3 = Request.Form("rentalreimbursement3") strtowing1 = Request.Form("towing1") strtowing2 = Request.Form("towing2") strtowing3 = Request.Form("towing3") struse1 = Request.Form("use1") struse2 = Request.Form("use2") struse3 = Request.Form("use3") strantitheft1 = Request.Form("antitheft1") strantitheft2 = Request.Form("antitheft2") strantitheft3 = Request.Form("antitheft3") strantilockbrakes1 = Request.Form("antilockbrakes1") strantilockbrakes2 = Request.Form("antilockbrakes2") strantilockbrakes3 = Request.Form("antilockbrakes3") strpassiverestraint1 = Request.Form("passiverestraint1") strpassiverestraint2 = Request.Form("passiverestraint2") strpassiverestraint3 = Request.Form("passiverestraint3") strmilestowork1 = Request.Form("milestowork1") strmilestowork2 = Request.Form("milestowork2") strmilestowork3 = Request.Form("milestowork3") strannualmileage1 = Request.Form("annualmileage1") strannualmileage2 = Request.Form("annualmileage2") strannualmileage3 = Request.Form("annualmileage3") If (strname <> "") AND _ (stremail <> "") AND _ (strtelephone <> "") AND _ (straddress <> "") AND _ (strzipcode <> "") AND _ (strdrivername1 <> "") AND _ (stroperator1 <> "") AND _ (strdateofbirth1 <> "") AND _ (strsex1 <> "") AND _ (strmaritalstatus1 <> "") AND _ (strtrafficviolations1 <> "") AND _ (strcurrentlyinsured1 <> "") AND _ (strhomeowner <> "") AND _ (stryearmakemodel1 <> "") AND _ (strgaragingzip <> "") AND _ (strtort <> "") AND _ (strliabilitylimits <> "") AND _ (strfirstpartybenefits <> "") AND _ (strworkloss <> "") AND _ (strfuneralexpense <> "") AND _ (straccidentaldeath <> "") AND _ (strextraordinarymedicalbenefits <> "") AND _ (struninsuredmotorist <> "") AND _ (strunderinsuredmotorist <> "") AND _ (strcomprehensivedeductible1 <> "") AND _ (strcollisiondeductible1 <> "") AND _ (strrentalreimbursement1 <> "") AND _ (strtowing1 <> "") AND _ (struse1 <> "") AND _ (strantitheft1 <> "") AND _ (strantilockbrakes1 <> "") AND _ (strpassiverestraint1 <> "") AND _ (strmilestowork1 <> "") Then %> <% set Mailer = server.createobject("CDO.Message") Mailer.Configuration.Fields.Item("http://schemas.microsoft.com/cdo/configuration/sendusing") = 2 Mailer.Configuration.Fields.Item("http://schemas.microsoft.com/cdo/configuration/smtpserver") = "mail.nauticom.net" Mailer.Configuration.Fields.Item("http://schemas.microsoft.com/cdo/configuration/smtpserverport") = 25 Mailer.Configuration.Fields.Update ' create email message body 'Dim strMessageBody = "" ' applicant information strMessageBody = "--Name--: " & strname & VBCrLf strMessageBody = strMessageBody & "--Email--: " & stremail & VBCrLf strMessageBody = strMessageBody & "--Telephone--: " & strtelephone & VBCrLf strMessageBody = strMessageBody & "--Fax--: " & strfax & VBCrLf strMessageBody = strMessageBody & "--Address--: " & straddress & VBCrLf strMessageBody = strMessageBody & "--Zipcode--: " & strzipcode & VBCrLf strMessageBody = strMessageBody & "--Best Time to Call--: " & strbesttimetocall & VBCrLf ' driver #1 information strMessageBody = strMessageBody & VBCrLf & "-=Driver #1 Information=-" & VBCrLf strMessageBody = strMessageBody & VBCrLf & "--Driver Name--: " & strdrivername1 & VBCrLf strMessageBody = strMessageBody & "--Operator Number--: " & stroperator1 & VBCrLf strMessageBody = strMessageBody & "--Date of Birth--: " & strdateofbirth1 & VBCrLf strMessageBody = strMessageBody & "--Sex--: " & strsex1 & VBCrLf strMessageBody = strMessageBody & "--Marital Status: " & strmaritalstatus1 & VBCrLf strMessageBody = strMessageBody & "--Traffic Violations--: " & strtrafficviolations1 & VBCrLf strMessageBody = strMessageBody & "--Currently Insured--: " & strcurrentlyinsured1 & VBCrLf ' optional driver #2 information If (strdrivername2 <> "") Then strMessageBody = strMessageBody & VBCrLf & "-=Driver #2 Information=-" & VBCrLf strMessageBody = strMessageBody & VBCrLf & "--Driver Name---: " & strdrivername2 & VBCrLf strMessageBody = strMessageBody & "--Operator Number--: " & stroperator2 & VBCrLf strMessageBody = strMessageBody & "--Date of Birth--: " & strdateofbirth2 & VBCrLf strMessageBody = strMessageBody & "--Sex--: " & strsex2 & VBCrLf strMessageBody = strMessageBody & "--Marital Status--: " & strmaritalstatus2 & VBCrLf strMessageBody = strMessageBody & "--Traffic Violations--: " & strtrafficviolations2 & VBCrLf strMessageBody = strMessageBody & "--Currently Insured--: " & strcurrentlyinsured2 & VBCrLf End If ' optional driver #3 information If (strdrivername3 <> "") Then strMessageBody = strMessageBody & VBCrLf & "-=Driver #3 Information=-" & VBCrLf strMessageBody = strMessageBody & VBCrLf & "--Driver Name: " & strdrivername3 & VBCrLf strMessageBody = strMessageBody & "--Operator Number--: " & stroperator3 & VBCrLf strMessageBody = strMessageBody & "--Date of Birth--: " & strdateofbirth3 & VBCrLf strMessageBody = strMessageBody & "--Sex--: " & strsex3 & VBCrLf strMessageBody = strMessageBody & "--Marital Status--: " & strmaritalstatus3 & VBCrLf strMessageBody = strMessageBody & "--Traffic Violations--: " & strtrafficviolations3 & VBCrLf strMessageBody = strMessageBody & "--Currently Insured--: " & strcurrentlyinsured3 & VBCrLf End If ' global driver information strMessageBody = strMessageBody & VBCrLf & "-=Global Driver Information=-" & VBCrLf & VBCrLf If (strtrafficviolations1 = "yes") Or (strtrafficviolations2 = "yes") Or (strtrafficviolations3 = "yes") Then strMessageBody = strMessageBody & "--Violation Explanation--: " & strviolationexplanation & VBCrLf End If strMessageBody = strMessageBody & "--Current Carrier--: " & strcurrentcarrier & VBCrLf strMessageBody = strMessageBody & "--Home Owner--: " & strhomeowner & VBCrLf ' vehicle #1 information strMessageBody = strMessageBody & VBCrLf & "-=Vehicle #1 Information=-" & VBCrLf strMessageBody = strMessageBody & VBCrLf & "--Year/Make/Model--: " & stryearmakemodel1 & VBCrLf strMessageBody = strMessageBody & "--Comprehensive Deductible--: " & strcomprehensivedeductible1 & VBCrLf strMessageBody = strMessageBody & "--Collision Deductible--: " & strcollisiondeductible1 & VBCrLf strMessageBody = strMessageBody & "--Rental Reimbursement--: " & strrentalreimbursement1 & VBCrLf strMessageBody = strMessageBody & "--Towing--: " & strtowing1 & VBCrLf strMessageBody = strMessageBody & "--Use--: " & struse1 & VBCrLf strMessageBody = strMessageBody & "--Anti-Theft--: " & strantitheft1 & VBCrLf strMessageBody = strMessageBody & "--Anti-Lock Brakes--: " & strantilockbrakes1 & VBCrLf strMessageBody = strMessageBody & "--Passive Restraint--: " & strpassiverestraint1 & VBCrLf strMessageBody = strMessageBody & "--Miles to Work--: " & strmilestowork1 & VBCrLf strMessageBody = strMessageBody & "--Annual Mileage--: " & strannualmileage1 & VBCrLf ' optional vehicle #2 information If (stryearmakemodel2 <> "") Then strMessageBody = strMessageBody & VBCrLf & "-=Vehicle #2 Information=-" & VBCrLf strMessageBody = strMessageBody & VBCrLf & "--Year/Make/Model--: " & stryearmakemodel2 & VBCrLf strMessageBody = strMessageBody & "--Comprehensive Deductible--: " & strcomprehensivedeductible2 & VBCrLf strMessageBody = strMessageBody & "--Collision Deductible--: " & strcollisiondeductible2 & VBCrLf strMessageBody = strMessageBody & "--Rental Reimbursement--: " & strrentalreimbursement2 & VBCrLf strMessageBody = strMessageBody & "--Towing--: " & strtowing2 & VBCrLf strMessageBody = strMessageBody & "--Use--: " & struse2 & VBCrLf strMessageBody = strMessageBody & "--Anti-Theft--: " & strantitheft2 & VBCrLf strMessageBody = strMessageBody & "--Anti-Lock Brakes--: " & strantilockbrakes2 & VBCrLf strMessageBody = strMessageBody & "--Passive Restraint--: " & strpassiverestraint2 & VBCrLf strMessageBody = strMessageBody & "--Miles to Work--: " & strmilestowork2 & VBCrLf strMessageBody = strMessageBody & "--Annual Mileage--: " & strannualmileage2 & VBCrLf End If ' optional vehicle #3 information If (stryearmakemodel3 <> "") Then strMessageBody = strMessageBody & VBCrLf & "-=Vehicle #3 Information=-" & VBCrLf strMessageBody = strMessageBody & VBCrLf & "--Year/Make/Model--: " & stryearmakemodel3 & VBCrLf strMessageBody = strMessageBody & "--Comprehensive Deductible--: " & strcomprehensivedeductible3 & VBCrLf strMessageBody = strMessageBody & "--Collision Deductible--: " & strcollisiondeductible3 & VBCrLf strMessageBody = strMessageBody & "--Rental Reimbursement--: " & strrentalreimbursement3 & VBCrLf strMessageBody = strMessageBody & "--Towing--: " & strtowing3 & VBCrLf strMessageBody = strMessageBody & "--Use--: " & struse3 & VBCrLf strMessageBody = strMessageBody & "--Anti-Theft--: " & strantitheft3 & VBCrLf strMessageBody = strMessageBody & "--Anti-Lock Brakes--: " & strantilockbrakes3 & VBCrLf strMessageBody = strMessageBody & "--Passive Restraint--: " & strpassiverestraint3 & VBCrLf strMessageBody = strMessageBody & "--Miles to Work--: " & strmilestowork3 & VBCrLf strMessageBody = strMessageBody & "--Annual Mileage--: " & strannualmileage3 & VBCrLf End If ' global vehicle information strMessageBody = strMessageBody & VBCrLf & "-=Global Vehicle Information=-" & VBCrLf strMessageBody = strMessageBody & VBCrLf & "--Garaging Zip--: " & strgaragingzip & VBCrLf strMessageBody = strMessageBody & "--Tort--: " & strtort & VBCrLf strMessageBody = strMessageBody & "--Liability Limits--: " & strliabilitylimits & VBCrLf strMessageBody = strMessageBody & "--First Party Benefits--: " & strfirstpartybenefits & VBCrLf strMessageBody = strMessageBody & "--Work Loss--: " & strworkloss & VBCrLf strMessageBody = strMessageBody & "--Funeral Expense--: " & strfuneralexpense & VBCrLf strMessageBody = strMessageBody & "--Accidental Death--: " & straccidentaldeath & VBCrLf strMessageBody = strMessageBody & "--Extraordinary Medical Benefits--: " & strextraordinarymedicalbenefits & VBCrLf strMessageBody = strMessageBody & "--Uninsured Motorist--: " & struninsuredmotorist & VBCrLf strMessageBody = strMessageBody & "--Underinsured Motorist--: " & strunderinsuredmotorist & VBCrLf ' send mail Mailer.From = "The Heberling Wesite" Mailer.To = "jheberling@heberlinginsurance.com" Mailer.Subject = "Auto Application from Web" Mailer.textBody = strMessageBody Mailer.Send Else %>