"; } if (!empty($error)) { $errorcode = file_get_contents($error_url); $replace = "##error##"; $errorcode = str_replace($replace, $error, $errorcode); echo $errorcode; exit; } $internalfields = array ("submit", "reset", "send", "captcha_code"); $message .= $eol; $message .= "IP Address : "; $message .= $_SERVER['REMOTE_ADDR']; $message .= $eol; foreach ($_POST as $key => $value) { if (!in_array(strtolower($key), $internalfields)) { if (!is_array($value)) { $message .= ucwords(str_replace("_", " ", $key)) . " : " . $value . $eol; } else { $message .= ucwords(str_replace("_", " ", $key)) . " : " . implode(",", $value) . $eol; } } } $body = 'This is a multi-part message in MIME format.'.$eol.$eol; $body .= '--'.$boundary.$eol; $body .= 'Content-Type: text/plain; charset=ISO-8859-1'.$eol; $body .= 'Content-Transfer-Encoding: 8bit'.$eol; $body .= $eol.stripslashes($message).$eol; if (!empty($_FILES)) { foreach ($_FILES as $key => $value) { if ($_FILES[$key]['error'] == 0 && $_FILES[$key]['size'] <= $max_filesize) { $body .= '--'.$boundary.$eol; $body .= 'Content-Type: '.$_FILES[$key]['type'].'; name='.$_FILES[$key]['name'].$eol; $body .= 'Content-Transfer-Encoding: base64'.$eol; $body .= 'Content-Disposition: attachment; filename='.$_FILES[$key]['name'].$eol; $body .= $eol.chunk_split(base64_encode(file_get_contents($_FILES[$key]['tmp_name']))).$eol; } } } $body .= '--'.$boundary.'--'.$eol; mail($mailto, $subject, $body, $header); header('Location: '.$success_url); exit; } ?> Untitled Page
First Name *
Last Name*
Contact Number*
Address*
City*
State*
Zip*
Drivers (Including Yourself)*
Name-DOB-Marital Status
Accidents,Tickets,Violation in the last 3 years
(Type/Date)
Vehicle Information*
Year, Make, Model or VIN
Special Or Aftermarket Equipment Coverage
Full Coverage
Full Coverage
Full Coverage
Full Coverage
Full Coverage
Deductibles
Comprehensive
Liability
Liability
Liability
Liability
Liability
Collision
Towing
Coverage
Bodily Injury
Property Damage
Uninsured Motorist
    Bodily Injury
Medical Payments
Discounts*
Continuos Prior Coverage for 6 Months
Prior Limits
Homeowner
Military
Defensive Driving Course
(
Home
Mobile Home)
Good Student
Social Security #
(Optional but may provide a better rate)
Rental