<% Action = Left(UCase(Request("Action")),4) fm_name = request.form("fm_name") fm_email = request.form("fm_email") IF Action = "SEND" AND fm_name <> "" and fm_email <> "" THEN Set Mailer = Server.CreateObject("SMTPsvg.Mailer") Mailer.FromName = fm_name Mailer.FromAddress = fm_email Mailer.RemoteHost = "custmail.s7systems.com" Mailer.Encoding = 2 Mailer.AddRecipient "info@cheapwc.com","info@cheapwc.com" Mailer.AddBCC "jason@jestec.com","jason@jestec.com" Mailer.Subject = "Certificate Request Form" strBody = strBody & "Contact Request form submitted to Rick Johnson Insurance on " & NOW & Chr(13) & Chr(10) & Chr(13) & Chr(10) strBody = strBody & "Name.................: " & fm_name & Chr(13) & Chr(10) strBody = strBody & "Email................: " & fm_email & Chr(13) & Chr(10) strBody = strBody & "Certificate Holder...: " & request("fm_certificate") & Chr(13) & Chr(10) strBody = strBody & "Attention............: " & request("fm_attn") & Chr(13) & Chr(10) strBody = strBody & "Fax..................: " & request("fm_fax") & Chr(13) & Chr(10) strBody = strBody & "General Liability....: " & request("fm_general") & Chr(13) & Chr(10) strBody = strBody & "Business Auto........: " & request("fm_auto") & Chr(13) & Chr(10) strBody = strBody & "Workers Compensation.: " & request("fm_worker") & Chr(13) & Chr(10) strBody = strBody & "Amount of Contract...: " & request("fm_amt") & Chr(13) & Chr(10) strBody = strBody & "Type of work.........: " & request("fm_type") & Chr(13) & Chr(10) strBody = strBody & "Start Date...........: " & request("fm_start") & Chr(13) & Chr(10) strBody = strBody & "End Date.............: " & request("fm_end") & Chr(13) & Chr(10) Mailer.BodyText = strBody Mailer.SendMail If Request("fm_redir") = "on" Then Response.Redirect "questionnaire.asp" Else Response.Redirect "thankyou.htm" End If END IF %> Certificate Request Form

Please complete this form and submit it, and our staff will get back to you quickly to take care of your needs.

Name of Insured: 
Email: 
Certificate  
Holder: 
Attn: 
Fax: 

   General Liabilty
   Business Auto
   Workers Compensation

Contract Amount: 
Type of Work: 
Start Date: 
End Date: 
  I will need an addtional
insured endorsement





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