| Contact
Information: |
|
| * Name: | |
| * Email Address: | |
| * Telephone: | |
| Fax: | |
| * Address: | |
| * Zip Code: | |
| Best time to call: | |
| * Date of Birth: | |
| * Sex: | > Male > Female |
| * Type of Coverage: | > Single > Married > Family |
| * Smoking: | > Smoker > Non Smoker |
| * Health Problems: | |
| Questions or Concerns: | |
* - 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") strDateOfBirth = Request.Form("dateofbirth") strSex = Request.Form("sex") strSmoking = Request.Form("smoking") strTypeOfCoverage = Request.Form("typeofcoverage") strHealthProblems = Request.Form("healthproblems") strQuestionsConcerns = Request.Form("questionsconcerns") If (strName <> "") and (strEmail <> "") and (strTelephone <> "") _ and (strAddress <> "") and (strZipCode <> "") _ and (strDateOfBirth <> "") _ and (strSex <> "") and (strSmoking <> "") and (strTypeOfCoverage <> "") and _ (strHealthProblems <> "") Then %> <% Call HealthQuoteForm End If Else Call HealthQuoteForm End If %>