| Contact
Information: |
|
| * Name: | |
| * Email Address: | "> |
| * Telephone: | |
| Fax: | |
| * Address: | |
| * Zip Code: | |
| Best time to call: | |
| * Date of Birth: | |
| * Height: | |
| * Weight: | |
| * Sex: | >Male >Female |
| * Marital Status: | >Single >Married >Family |
| Occupation: | |
| * Smoking: | >Smoker >Non Smoker |
| * Type of Coverage: | >Term Life >Universal Life |
| * Amount: | |
| 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") strHeight = Request.Form("height") strWeight = Request.Form("weight") strSex = Request.Form("sex") strMaritalStatus = Request.Form("maritalstatus") strOccupation = Request.Form("occupation") strSmoking = Request.Form("smoking") strTypeOfCoverage = Request.Form("typeofcoverage") strAmount = Request.Form("amount") strQuestionsConcerns = Request.Form("questionsconcerns") If (strName <> "") and (strEmail <> "") and (strTelephone <> "") _ and (strAddress <> "") and (strZipCode <> "") _ and (strDateOfBirth <> "") _ and (strHeight <> "") and (strWeight <> "") and (strSex <> "") _ and (strMaritalStatus <> "") and _ (strSmoking <> "") and (strTypeOfCoverage <> "") and _ (strAmount <> "") Then %><% Call LifeQuoteForm End If Else Call LifeQuoteForm End If %>