<% 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 = "Additional Insured Questionnaire" strBody = strBody & "Questionnaire 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 & "Phone..: " & Request("fm_phone") & Chr(13) & Chr(10) strBody = strBody & "Name of Entity requesting to be added...........: " & Request("fm_comments1") & Chr(13) & Chr(10) strBody = strBody & "Operations of Entity requesting to be added.....: " & Request("fm_comments2") & Chr(13) & Chr(10) strBody = strBody & "Relationship between named & additional.........: " & Request("fm_comments3") & Chr(13) & Chr(10) strBody = strBody & "Type of work to be done for Additional..........: " & Request("fm_comments4") & Chr(13) & Chr(10) strBody = strBody & "Type of work to be done for Additional..........: " & Request("fm_comments4") & Chr(13) & Chr(10) strBody = strBody & "Is there a written contract between groups?.....: " & Request("fm_written") & Chr(13) & Chr(10) strBody = strBody & "Contract cost of work to be done by additional..: " & Request("fm_additional") & Chr(13) & Chr(10) strBody = strBody & "Does additional maintain primary insurance?.....: " & Request("fm_primary") & Chr(13) & Chr(10) Mailer.BodyText = strBody Mailer.SendMail Response.Redirect "thankyou.htm" END IF %> Questionnaire

Please fill out this form to address any additional insured individuals that you wish to add to an existing insurance policy.

Named Insured: 
Email Address: 
Policy No: 
 
Name of entity requesting to be
added as an additional insured:


Operations of entity requesting to
be added as Additional insured:


Explain relationship between Named
insured and Additional insured:


Type of work to be done
for the Additional Insured:


Is there a written contract between the
Named Insured and the Additional Insured?

Yes  No

Contract cost to be done for the
Additonal Insured:

Does the Additonal insured maintain primary insurance to cover the exposure
or risk?

Yes  No



Copyright 2001 Rick Johnson Insurance   www.cheapwc.com    Fax: 925 370-8042   Tel: (800) 640-4005   Lic # 0551190