Forum Moderators: coopster
<?php
if ($_SERVER['REQUEST_METHOD'] != 'POST'){
$me = $_SERVER['PHP_SELF'];
?>
<form name="form1" method="post"
action="<?php echo $me;?>">
<form>.....</form>
<?php
} else {
error_reporting(0);
$recipient = 'contact@example.com';
$in_name = stripslashes($_POST['i_name']);
$la_name = stripslashes($_POST['l_name']);
$in_street = stripslashes($_POST['i_street']);
$in_city_prov = stripslashes($_POST['i_city_prov']);
$in_pcode = stripslashes($_POST['i_pcode']);
$in_phone = stripslashes($_POST['i_phone']);
$brokerage = stripslashes($_POST['brokerage']);
$br_street = stripslashes($_POST['b_street']);
$br_city_prov = stripslashes($_POST['b_city_prov']);
$br_pcode = stripslashes($_POST['b_pcode']);
$br_phone = stripslashes($_POST['b_phone']);
$ext = stripslashes($_POST['ext']);
$br_con_nam = stripslashes($_POST['b_con_nam']);
$br_con_email = stripslashes($_POST['b_con_email']);
$financed = stripslashes($_POST['p_financed']);
$p_num1 = stripslashes($_POST['pol_num1']);
$mon1 = stripslashes($_POST['month1']);
$day1 = stripslashes($_POST['day1']);
$yr1 = stripslashes($_POST['year1']);
$ins_com1 = stripslashes($_POST['ins_com1']);
$type1 = stripslashes($_POST['type1']);
$t_mon_yr1 = stripslashes($_POST['term_mon_yr1']);
$prem1 = stripslashes($_POST['premium1']);
$fee1 = stripslashes($_POST['fees1']);
$cfee1 = stripslashes($_POST['cfees1']);
$tax1 = stripslashes($_POST['tax1']);
$p_num2 = stripslashes($_POST['pol_num2']);
$mon2 = stripslashes($_POST['month2']);
$day2 = stripslashes($_POST['day2']);
$yr2 = stripslashes($_POST['year2']);
$ins_com2 = stripslashes($_POST['ins_com2']);
$type2 = stripslashes($_POST['type2']);
$t_mon_yr2 = stripslashes($_POST['term_mon_yr2']);
$prem2 = stripslashes($_POST['premium2']);
$fee2 = stripslashes($_POST['fees2']);
$cfee2 = stripslashes($_POST['cfees2']);
$tax2 = stripslashes($_POST['tax2']);
$p_num3 = stripslashes($_POST['pol_num3']);
$mon3 = stripslashes($_POST['month3']);
$day3 = stripslashes($_POST['day3']);
$yr3 = stripslashes($_POST['year3']);
$ins_com3 = stripslashes($_POST['ins_com3']);
$type3 = stripslashes($_POST['type3']);
$t_mon_yr3 = stripslashes($_POST['term_mon_yr3']);
$prem3 = stripslashes($_POST['premium3']);
$fee3 = stripslashes($_POST['fees3']);
$cfee3 = stripslashes($_POST['cfees3']);
$tax3 = stripslashes($_POST['tax3']);
$p_num4 = stripslashes($_POST['pol_num4']);
$mon4 = stripslashes($_POST['month4']);
$day4 = stripslashes($_POST['day4']);
$yr4 = stripslashes($_POST['year4']);
$ins_com4 = stripslashes($_POST['ins_com4']);
$type4 = stripslashes($_POST['type4']);
$t_mon_yr4 = stripslashes($_POST['term_mon_yr4']);
$prem4 = stripslashes($_POST['premium4']);
$fee4 = stripslashes($_POST['fees4']);
$cfee4 = stripslashes($_POST['cfees4']);
$tax4 = stripslashes($_POST['tax4']);
$p_num5 = stripslashes($_POST['pol_num5']);
$mon5 = stripslashes($_POST['month5']);
$day5 = stripslashes($_POST['day5']);
$yr5 = stripslashes($_POST['year5']);
$ins_com5 = stripslashes($_POST['ins_com5']);
$type5 = stripslashes($_POST['type5']);
$t_mon_yr5 = stripslashes($_POST['term_mon_yr5']);
$prem5 = stripslashes($_POST['premium5']);
$fee5 = stripslashes($_POST['fees5']);
$cfee5 = stripslashes($_POST['cfees5']);
$tax5 = stripslashes($_POST['tax5']);
$p_num6 = stripslashes($_POST['pol_num6']);
$mon6 = stripslashes($_POST['month6']);
$day6 = stripslashes($_POST['day6']);
$yr6 = stripslashes($_POST['year6']);
$ins_com6 = stripslashes($_POST['ins_com6']);
$type6 = stripslashes($_POST['type6']);
$t_mon_yr6 = stripslashes($_POST['term_mon_yr6']);
$prem6 = stripslashes($_POST['premium6']);
$fee6 = stripslashes($_POST['fees6']);
$cfee6 = stripslashes($_POST['cfees6']);
$tax6 = stripslashes($_POST['tax6']);
$p_num7 = stripslashes($_POST['pol_num7']);
$mon7 = stripslashes($_POST['month7']);
$day7 = stripslashes($_POST['day7']);
$yr7 = stripslashes($_POST['year7']);
$ins_com7 = stripslashes($_POST['ins_com7']);
$type7 = stripslashes($_POST['type7']);
$t_mon_yr7 = stripslashes($_POST['term_mon_yr7']);
$prem7 = stripslashes($_POST['premium7']);
$fee7 = stripslashes($_POST['fees7']);
$cfee7 = stripslashes($_POST['cfees7']);
$tax7 = stripslashes($_POST['tax7']);
$p_num8 = stripslashes($_POST['pol_num8']);
$mon8 = stripslashes($_POST['month8']);
$day8 = stripslashes($_POST['day8']);
$yr8 = stripslashes($_POST['year8']);
$ins_com8 = stripslashes($_POST['ins_com8']);
$type8 = stripslashes($_POST['type8']);
$t_mon_yr8 = stripslashes($_POST['term_mon_yr8']);
$prem8 = stripslashes($_POST['premium8']);
$fee8 = stripslashes($_POST['fees8']);
$cfee8 = stripslashes($_POST['cfees8']);
$tax8 = stripslashes($_POST['tax8']);
$headers = "From: $br_con_email\r\n\r\n";
$subject = "Quick Quote Form from Website";
$message = "First Name: $in_name\r\n
Last Name: $la_name\r\n
Insured Street Address: $in_street\r\n
Insured City & Province: $in_city_prov\r\n
Insured Postal Code: $in_pcode\r\n
Insured Phone Number: $in_phone\r\n
Brokerage: $brokerage\r\n
Broker Street Address: $br_street\r\n
Broker City & Province: $br_city_prov\r\n
Broker Postal Code: $br_pcode\r\n
Broker Phone Number: $br_phone\r\n
Broker Phone Ext: $ext\r\n
Broker Name: $br_con_nam\r\n
Broker Email: $br_con_email\r\n
Policy Number: $p_num1 Effective Date: $mon1 $day1 $yr1 Ins. Company: $ins_com1 Type Of Coverage: $type1 Term: $t_mon_yr1 Policy Premium: $prem1 Policy Fee: $fee1 Company Fee: $cfee1 Sales Tax: $tax1 \r\n
Policy Number: $p_num2 Effective Date: $mon2 $day2 $yr2 Ins. Company: $ins_com2 Type Of Coverage: $type2 Term: $t_mon_yr2 Policy Premium: $prem2 Policy Fee: $fee2 Company Fee: $cfee2 Sales Tax: $tax2 \r\n
Policy Number: $p_num3 Effective Date: $mon3 $day3 $yr3 Ins. Company: $ins_com3 Type Of Coverage: $type3 Term: $t_mon_yr3 Policy Premium: $prem3 Policy Fee: $fee3 Company Fee: $cfee3 Sales Tax: $tax3 \r\n
Policy Number: $p_num4 Effective Date: $mon4 $day4 $yr4 Ins. Company: $ins_com4 Type Of Coverage: $type4 Term: $t_mon_yr4 Policy Premium: $prem4 Policy Fee: $fee4 Company Fee: $cfee4 Sales Tax: $tax4 \r\n
Policy Number: $p_num5 Effective Date: $mon5 $day5 $yr5 Ins. Company: $ins_com5 Type Of Coverage: $type5 Term: $t_mon_yr5 Policy Premium: $prem5 Policy Fee: $fee5 Company Fee: $cfee5 Sales Tax: $tax5 \r\n
Policy Number: $p_num6 Effective Date: $mon6 $day6 $yr6 Ins. Company: $ins_com6 Type Of Coverage: $type6 Term: $t_mon_yr6 Policy Premium: $prem6 Policy Fee: $fee6 Company Fee: $cfee6 Sales Tax: $tax6 \r\n
Policy Number: $p_num7 Effective Date: $mon7 $day7 $yr7 Ins. Company: $ins_com7 Type Of Coverage: $type7 Term: $t_mon_yr7 Policy Premium: $prem7 Policy Fee: $fee7 Company Fee: $cfee7 Sales Tax: $tax7 \r\n
Policy Number: $p_num8 Effective Date: $mon8 $day8 $yr8 Ins. Company: $ins_com8 Type Of Coverage: $type8 Term: $t_mon_yr8 Policy Premium: $prem8 Policy Fee: $fee8 Company Fee: $cfee8 Sales Tax: $tax8 \r\n
";
mail($recipient, $subject, $message, $headers);
if (!mail) {
echo "Message failed to send";
} else {
echo nl2br ("<center><br><br><br><br><br><br><br><br><br><br>Thank you. Your request has been sent and we will contact you shortly.<br><br><br><br><br><br><br><br><br><br></center>");
}
}
?> [edited by: eelixduppy at 9:06 pm (utc) on Apr 28, 2010]
[edit reason] exemplified [/edit]