<%
    Function DoubleQuotes(str)
        If NOT IsNull(str) Then DoubleQuotes = Trim(Replace(str,"""","&quot;")) Else DoubleQuotes = ""
    End Function
    
    Function NoTags(str)
        NoTags = Trim(Replace(Replace(str,">","&gt;"),"<","&lt;"))
    End Function
    
    Function SingleQuotes(str)
        SingleQuotes = Trim(Replace(str,"'","''"))
    End Function
    
    Function IsValidEmail(Email)
        ValidFlag = False
        If (Email <> "") And (InStr(1, Email, "@") > 0) And (InStr(1, Email, ".") > 0) Then
        atCount = 0
        SpecialFlag = False
        For atLoop = 1 To Len(Email)
        atChr = Mid(Email, atLoop, 1)
        If atChr = "@" Then atCount = atCount + 1
        If (atChr >= Chr(32)) And (atChr <= Chr(44)) Then SpecialFlag = True
        If (atChr = Chr(47)) Or (atChr = Chr(96)) Or (atChr >= Chr(123)) Then SpecialFlag = True
        If (atChr >= Chr(58)) And (atChr <= Chr(63)) Then SpecialFlag = True
        If (atChr >= Chr(91)) And (atChr <= Chr(94)) Then SpecialFlag = True
        Next
        If (atCount = 1) And (SpecialFlag = False) Then
        BadFlag = False
        tAry1 = Split(Email, "@")
        UserName = tAry1(0)
        DomainName = tAry1(1)
        If (UserName = "") Or (DomainName = "") Then BadFlag = True
        If Mid(DomainName, 1, 1) = "." then BadFlag = True
        If Mid(DomainName, Len(DomainName), 1) = "." then BadFlag = True
        ValidFlag = True
        End If
        End If
        If BadFlag = True Then ValidFlag = False
        IsValidEmail = ValidFlag
    End Function

formsubmitted = (Request.Form("formsubmitted")="1")
'Response.Write formsubmitted
'Response.End

if formsubmitted AND trim(request.form("name")) <> "" AND trim(request.form("city")) <> "" AND trim(request.form("state")) <> "" _
   AND IsValidEmail(request.form("email")) AND trim(request.form("name1")) <> "" AND trim(request.form("dob1")) <> "" _
   AND trim(request.form("vehicle1")) <> "" AND trim(request.form("vin1")) <> "" AND trim(request.form("ssn"))<>"" then
        EmailBody = "Name: " & request.form("name") & chr(13) _
            & "Address: " & request.form("address") & chr(13) _
            & "City: " & request.form("city") & chr(13) _
            & "Zip: " & request.form("zip") & chr(13) _
            & "State: " & request.form("state") & chr(13) & chr(13)_
            & "SSN: " & request.form("ssn") & chr(13) _
            & "Email: " & request.form("email") & chr(13) _
            & "Phone: " & request.form("phone") & chr(13) _
            & "Fax: " & request.form("fax") & chr(13) & chr(13) & chr(13) _
            & "Current Insurer: " & request.form("insurer") & chr(13) _
            & "Expiration Date: " & request.form("date") & chr(13) & chr(13) _
            & "Vehicle " & chr(13) _
            & "Vehicle #1 Info: " & request.form("vehicle1") & chr(13) _
            & "Vehicle #2 Info: " & request.form("vehicle2") & chr(13) _
            & "Vehicle #3 Info: " & request.form("vehicle3") & chr(13) _
            & "Vehicle #4 Info: " & request.form("vehicle4") & chr(13) & chr(13) _
            & "Vin Number " & chr(13) _
            & "VIN #1: " & request.form("vin1") & chr(13) _
            & "VIN #2: " & request.form("vin2") & chr(13) _
            & "VIN #3: " & request.form("vin3") & chr(13) _
            & "VIN #4: " & request.form("vin4") & chr(13) & chr(13) _
            & "Driver Information " & chr(13) _
            & "Driver #1" & chr(13) _
            & "Name: " & request.form("name1") & chr(13) _
            & "DOB: " & request.form("dob1") & chr(13) _
            & "License #: " & request.form("license1") & chr(13) _
            & "Drive vehicle #: " & request.form("license1") & chr(13) _
            & "Record: " & chr(13) _
            & Request.Form("record1") & chr(13) & chr(13) _
            & "Driver #2" & chr(13) _
            & "Name: " & request.form("name2") & chr(13) _
            & "DOB: " & request.form("dob2") & chr(13) _
            & "License #: " & request.form("license2") & chr(13) _
            & "Drive vehicle #: " & request.form("license2") & chr(13) _
            & "Record: " & chr(13) _
            & Request.Form("record2") & chr(13) & chr(13) _
            & "Driver #3" & chr(13) _
            & "Name: " & request.form("name3") & chr(13) _
            & "DOB: " & request.form("dob3") & chr(13) _
            & "License #: " & request.form("license3") & chr(13) _
            & "Drive vehicle #: " & request.form("license3") & chr(13) _
            & "Record: " & chr(13) _
            & Request.Form("record3") & chr(13) & chr(13) _
            & "Driver #14" & chr(13) _
            & "Name: " & request.form("name4") & chr(13) _
            & "DOB: " & request.form("dob4") & chr(13) _
            & "License #: " & request.form("license4") & chr(13) _
            & "Drive vehicle #: " & request.form("license4") & chr(13) _
            & "Record: " & chr(13) _
            & Request.Form("record4") & chr(13) & chr(13) & chr(13) _
            & "Coverages" & chr(13) _
            & "Uninsured/Underinsured Motorist Coverages: " & Request.Form("coverage") & chr(13) & chr(13) _
            & "Medical Payments: " & Request.Form("medical") & chr(13) & chr(13) _
            & "Comprehensive/Other Than Collision" & chr(13) _
            & "Vehicle #1 Deductible: " & Request.Form("deductible1") & chr(13) _
            & "Vehicle #2 Deductible: " & Request.Form("deductible2") & chr(13) _
            & "Vehicle #3 Deductible: " & Request.Form("deductible3") & chr(13) _
            & "Vehicle #4 Deductible: " & Request.Form("deductible4") & chr(13) & chr(13) _
            & "Collision Deductible" & chr(13) _
            & "Vehicle #1: " & Request.Form("collision1") & chr(13) _
            & "Vehicle #2: " & Request.Form("collision2") & chr(13) _
            & "Vehicle #3: " & Request.Form("collision3") & chr(13) _
            & "Vehicle #4: " & Request.Form("collision4") & chr(13) & chr(13) _
            & "Towing Coverage: " & Request.Form("towing") & chr(13) _
            & "Rental Reimbursement Coverage: " & Request.Form("rental") & chr(13) & chr(13) _
            & "Respond by: " & request.form("respond") & chr(13) & chr(13) & chr(13) _
            & "Comments/Questions:" & chr(13) _
            & request.form("comments") & chr(13) & chr(13) _
            & "Submitted: " & FormatDateTime(Date(),2) & " at " & FormatDateTime(Now(),3) & " CST" & chr(13) & chr(13)
        
        EmailBody = "The following Auto Insurance Quote was submitted through the Frontier Bank site:" & chr(13) & chr(13) & EmailBody
        
        '************USING CDONTS***********************************
        set objMail = CreateObject("CDONTS.NewMail")
            objMail.To = "insurance@frontierbk.com;"
            objMail.BCC = ""
            objMail.From = trim(request.form("email"))
            objMail.Subject = "Frontier Bank - Auto Insurance Quote"
            objMail.Body = EmailBody
            objMail.Send        
        set objMail = nothing
        
        response.redirect("/quote_thanks.asp")
    end if
%>
<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN">
<html><!-- InstanceBegin template="/Templates/About.dwt" codeOutsideHTMLIsLocked="false" -->
    
    <head>
        <title><!--#include virtual="/library/globalpagetitle_ire.htm"--> - Insurance & Real Estate</title>
        <!--#include virtual="/include/head_ire.ink"-->
        <script langauge="JavaScript">
        <!--
            function popup_window(strURL, thewidth, theheight) {
                newWindow=window.open(strURL, '', 'toolbar=0,width='+thewidth+',height='+theheight+',left='+((screen.width/2)-(thewidth/2))+',top=100,directories=0,status=1,resizable=1,scrollbars=1,menubar=0');
                newWindow.focus();
            }
        //-->
        </script>
        <script langauge="JavaScript">
        <!--
            function getCalendarDate()
            {       
                var months = new Array(13);
                months[0] = "January";
                months[1] = "February";
                months[2] = "March";
                months[3] = "April";
                months[4] = "May";
                months[5] = "June";
                months[6] = "July";
                months[7] = "August";
                months[8] = "September";
                months[9] = "October";
                months[10] = "November";
                months[11] = "December";
                var now = new Date();
                var monthnumber = now.getMonth();
                var monthname = months[monthnumber];
                var monthday = now.getDate();
                var year = now.getYear();
                if(year < 2000) { year = year + 1900; }
                var dateString = monthname + 
                ' ' + 
                monthday + 
                ', ' + 
                year;
                return dateString;
                }
                
                function popup_window(strURL, thewidth, theheight) {
                    newWindow=window.open(strURL, '', 'toolbar=0,width='+thewidth+',height='+theheight+',left='+((screen.width/2)-(thewidth/2))+',top=100,directories=0,status=1,resizable=1,scrollbars=1,menubar=0');
                    newWindow.focus();
                }
            //-->
        </script>
        <link rel="Stylesheet" type="text/css" href="/stylesheets/style.css">
    </head>
    
    <script language="Javascript">
    <!--
        var testtext = this.location+'';
        if (testtext.indexOf('i=1') > -1) { alert('You are leaving the Frontier Bank site and entering the Frontier Insurance & Realty site.\n\nTo return to the Frontier Bank site at any time, click the "Back to Frontier Bank" button.'); }
    //-->
    </script>
    
    <body marginwidth=0 marginheight=0 leftmargin=0 rightmargin=0 topmargin=0 bottommargin=0 bgcolor="#FFFFFF">
        
        <!-- InstanceParam name="PageTitle" type="text" value="Insurance &amp; Real Estate" -->
        
        <table cellpadding=0 cellspacing=0 border=0 width="100%" height="100%"><tr>
            <td bgcolor="#DDDDDD" width="50%"><img src="pixel_clear.gif" width=1 height=1></td>
            <td bgcolor="#333333"><img src="pixel_clear.gif" width=1 height=1></td>
            <td valign="top" width=775>
                
                <table cellpadding=0 cellspacing=0 border=0 width=775>
                    <tr><td background="/images/bg4.gif" colspan=2>
                        <table cellpadding=0 cellspacing=0 border=0 width=775><tr>
                            <td width=165 background="/images/bg4.gif"><!--
                                --><img src="/images/common/pixel_clear.gif" width=111 height=34><!--
                                --><a href="/insurance_and_realestate.htm"><img src="/images/logo_1_ire.gif" width=54 height=34 border=0></a><!--
                            --></td>
                            <td valign=bottom nowrap align=right background="/images/bg4.gif"><!--
                                --><img src="/images/common/pixel_clear.gif" width=610 height=1><br>
                                <font class=smallblack><script language="Javascript">document.write(getCalendarDate());</script>&nbsp;</font>
                            </td>
                        </tr></table>
                    </td></tr>
                    <tr><td bgcolor="#6DAA6D" colspan=2><!--
                        --><img src="/images/common/pixel_clear.gif" width=109 height=5><!--
                        --><a href="/insurance_and_realestate.htm"><img src="/images/logo_2_ire.gif" width=31 height=5 border=0></a><!--
                        --><img src="/images/common/pixel_clear.gif" width=635 height=5><!--
                    --></td></tr>
                    <tr>
                        <td valign=top><!--
                            --><img src="/images/common/pixel_clear.gif" width=17 height=40><!--
                            --><a href="/insurance_and_realestate.htm"><img src="/images/logo_3_ire.gif" width=167 height=40 border=0></a><br><!--
                            --><img src="/images/common/pixel_clear.gif" width=1 height=4><!--
                        --></td>
                        <td valign=top align=right nowrap><!--
                            --><a href="/ire/real_estate.htm"><img src="/images/nav/ire_real_estate.gif" width=91 height=25 border=0></a><!--
                            --><a href="/ire/insurance.htm"><img src="/images/nav/ire_insurance.gif" width=79 height=25 border=0></a><!--
                            --><a href="http://www.frontierbk.com/default.asp"><img src="/images/nav/ire_back.gif" width=143 height=25 border=0></a><!--
                        --></td>
                    </tr>
                </table>
                <table cellpadding=0 cellspacing=0 border=0 width=775>
                    <tr>
                        <td nowrap><img src="/images/common/pixel_clear.gif" width=1 height=13></td>
                        <td valign=bottom nowrap width=33><img src="/images/misc3.gif" width=33 height=13></td>
                        <td valign=bottom width="100%" background="/images/bg1.gif"><img src="/images/common/pixel_clear.gif" width=550 height=13></td>
                    </tr>
                    <tr>
                        <td valign=top nowrap>
                            <table cellpadding=14 cellspacing=0 border=0><tr><td nowrap class=smallgrey>
                                <!--#include virtual="/library/locations_left.htm"-->
                            </td></tr></table>
                        </td>
                        <td width=33 background="/images/bg2.gif"><!--
                            --><img src="/images/common/pixel_clear.gif" width=33 height=50><!--
                            --><img src="/images/misc4.gif" width=33 height=201><!--
                        --></td>
                        <td width="100%" valign="top" class="black">
                        <!-- content start -->
                          <b class="bigblack"><!-- InstanceBeginEditable name="Page Title" -->Auto Insurance Quote <!-- InstanceEndEditable --></b><br/>
                          <br/>
                          Fill out and submit the from below to receive a free auto quote. Final premium is subject to information verification.<br/>
                          <br/>
                          Marked fields (<font class="smallred">*</font>) are required.<br/>
                          <br/>
                          <form name="home" action="autoquote.asp" method="post">
                          <b>Personal Information</b><br/>
                          <table width="550" cellpadding="1" cellspacing="0" border="0" class="black">
                          <tr>
                            <td width="80">Name:<font class="smallred">*</font></td>
                            <td width="470"><input type="text" name="name" value="<%if formsubmitted then Response.Write Request.Form("name")%>"><%if formsubmitted AND Trim(Request.Form("name"))="" then Response.Write " <font class=""smallred"">Type in your name.</font>"%></td>
                          </tr>
                          <tr>
                            <td width="80">Address:<font class="smallred">*</font></td>
                            <td width="470"><input type="text" name="address" value="<%if formsubmitted then Response.Write Request.Form("address")%>"></td>
                          </tr>
                          <tr>
                            <td width="80">City:<font class="smallred">*</font></td>
                            <td width="470"><input type="text" name="city" value="<%if formsubmitted then Response.Write Request.Form("city")%>"><%if formsubmitted AND Trim(Request.Form("city"))="" then Response.Write " <font class=""smallred"">Field cannot be empty.</font>"%></td>
                          </tr>
                          <tr>
                            <td width="80">Zip: </td>
                            <td width="470"><input type="text" size="8" name="zip" value="<%if formsubmitted then Response.Write Request.Form("zip")%>"></td>
                          </tr>
                          <tr>
                            <td width="80">State:<font class="smallred">*</font></td>
                            <td width="470">
                              <select name="state">
                                <option value="Iowa" <%if Request.Form("state")="Iowa" then Response.Write "selected"%>>Iowa</option>
                                <option value="South Dakota" <%if Request.Form("state")="South Dakota" then Response.Write "selected"%>>South Dakota</option>
                              </select>
                            </td>
                          </tr>
                          <tr>
                            <td width="80">SSN:<font class="smallred">*</font></td>
                            <td width="470"><input type="text" name="ssn" value="<%if formsubmitted then Response.Write Request.Form("ssn")%>"><%if formsubmitted AND Trim(Request.Form("ssn"))=""then Response.Write " <font class=""smallred"">Field cannot be empty</font>"%></td>
                          </tr>
                          <tr>
                            <td width="80">Email:<font class="smallred">*</font></td>
                            <td width="470"><input type="text" name="email" value="<%if formsubmitted then Response.Write Request.Form("email")%>"><%if formsubmitted AND NOT IsValidEmail(Request.Form("email")) then Response.Write " <font class=""smallred"">Type in a valid email.</font>"%></td>
                          </tr>
                          <tr>
                            <td width="80">Phone:</td>
                            <td width="470"><input type="text" name="phone" value="<%if formsubmitted then Response.Write Request.Form("phone")%>"></td>
                          </tr>
                          <tr>
                            <td width="80">Fax:</td>
                            <td width="470"><input type="text" name="fax" value="<%if formsubmitted then Response.Write Request.Form("fax")%>"></td>
                          </tr>
                          <tr>
                            <td colspan="2" height="10"><img src="/images/common/pixel_clear.gif" border="0" /></td>
                          </tr>
                          <tr>
                            <td colspan="2" height="2" bgcolor="#6DAA6D"><img src="/images/common/pixel_clear.gif" border="0" /></td>
                          </tr>
                          <tr>
                            <td colspan="2" height="10"><img src="/images/common/pixel_clear.gif" border="0" /></td>
                          </tr>
                          </table>
                          <b>Current Carrier Information</b><br/>
                          <table width="550" cellpadding="1" cellspacing="0" border="0" class="black">
                          <tr>
                            <td colspan="2">Who is your current insurance carrier (not agency)?</td>
                          </tr>
                          <tr>
                            <td width="150">Insurance carrier name:</td>
                            <td width="400"><input type="text" name="carrier" value="<%if formsubmitted then Response.Write Request.Form("carrier")%>"></td>
                          </tr>
                          <tr>
                            <td colspan="2">What is the expiration date of your current auto policy?</td>
                          </tr>
                          <tr>
                            <td width="150">Expiration Date:</td>
                            <td width="400"><input type="text" name="date" value="<%if formsubmitted then Response.Write Request.Form("date")%>"></td>
                          </tr>
                          <tr>
                            <td colspan="2" height="10"><img src="/images/common/pixel_clear.gif" border="0" /></td>
                          </tr>
                          <tr>
                            <td colspan="2" height="2" bgcolor="#6DAA6D"><img src="/images/common/pixel_clear.gif" border="0" /></td>
                          </tr>
                          <tr>
                            <td colspan="2" height="10"><img src="/images/common/pixel_clear.gif" border="0" /></td>
                          </tr>
                          </table>
                          <b>Vehicle Description</b><br/>
                          <table width="550" cellpadding="1" cellspacing="0" border="0" class="black">
                          <tr>
                            <td width="275">Vehicle #1 (Year, Make & Model)<font class="smallred">*</font></td>
                            <td width="275"><input type="text" name="vehicle1" value="<%if formsubmitted then Response.Write Request.Form("vehicle1")%>"></td>
                          </tr>
                          <tr>
                            <td width="275">Vehicle #2 (Year, Make & Model)</td>
                            <td width="275"><input type="text" name="vehicle2" value="<%if formsubmitted then Response.Write Request.Form("vehicle2")%>"></td>
                          </tr>
                          <tr>
                            <td width="275">Vehicle #3(Year, Make & Model)</td>
                            <td width="275"><input type="text" name="vehicle3" value="<%if formsubmitted then Response.Write Request.Form("vehicle3")%>"></td>
                          </tr>
                          <tr>
                            <td width="275">Vehicle #4 (Year, Make & Model)</td>
                            <td width="275"><input type="text" name="vehicle4" value="<%if formsubmitted then Response.Write Request.Form("vehicle4")%>"></td>
                          </tr>
                          <tr>
                            <td colspan="2" height="10"><img src="/images/common/pixel_clear.gif" border="0" /></td>
                          </tr>
                          <tr>
                            <td colspan="2" height="2" bgcolor="#6DAA6D"><img src="/images/common/pixel_clear.gif" border="0" /></td>
                          </tr>
                          <tr>
                            <td colspan="2" height="10"><img src="/images/common/pixel_clear.gif" border="0" /></td>
                          </tr>
                          </table>
                          <b>VIN Number</b><br/>
                          <table width="550" cellpadding="1" cellspacing="0" border="0" class="black">
                          <tr>
                            <td width="275">VIN #1 (Vehicle Identification Number)<font class="smallred">*</font></td>
                            <td width="275"><input type="text" name="vin1" value="<%if formsubmitted then Response.Write Request.Form("vin1")%>"></td>
                          </tr>
                          <tr>
                            <td width="275">VIN #2 (Vehicle Identification Number)</td>
                            <td width="275"><input type="text" name="vin2" value="<%if formsubmitted then Response.Write Request.Form("vin2")%>"></td>
                          </tr>
                          <tr>
                            <td width="275">VIN #3 (Vehicle Identification Number)</td>
                            <td width="275"><input type="text" name="vin3" value="<%if formsubmitted then Response.Write Request.Form("vin3")%>"></td>
                          </tr>
                          <tr>
                            <td width="275">VIN #4 (Vehicle Identification Number)</td>
                            <td width="275"><input type="text" name="vin4" value="<%if formsubmitted then Response.Write Request.Form("vin4")%>"></td>
                          </tr>
                          <tr>
                            <td colspan="2" height="10"><img src="/images/common/pixel_clear.gif" border="0" /></td>
                          </tr>
                          <tr>
                            <td colspan="2" height="2" bgcolor="#6DAA6D"><img src="/images/common/pixel_clear.gif" border="0" /></td>
                          </tr>
                          <tr>
                            <td colspan="2" height="10"><img src="/images/common/pixel_clear.gif" border="0" /></td>
                          </tr>
                          </table>
                          <b>Driver Information</b><br/>
                          <b>Driver #1</b><br/>
                          <table width="550" cellpadding="1" cellspacing="0" border="0" class="black">
                          <tr>
                            <td width="250">Driver's Name<font class="smallred">*</font></td>
                            <td width="300">
                              <input type="text" name="name1" value="<%if formsubmitted then Response.Write Request.Form("name1")%>">
                              <%if formsubmitted AND Trim(Request.Form("name1"))="" then Response.Write " <font class=""smallred"">Field cannot be empty</font>"%>
                            </td>
                          </tr>
                          <tr>
                            <td width="250">Date of Birth<font class="smallred">*</font></td>
                            <td width="300">
                               <input type="text" name="dob1" value="<%if formsubmitted then Response.Write Request.Form("dob1")%>">
                               <%if formsubmitted AND Trim(Request.Form("dob1"))="" then Response.Write " <font class=""smallred"">Field cannot be empty</font>"%>
                            </td>
                          </tr>
                          <tr>
                            <td width="250">Driver's License #<font class="smallred">*</font></td>
                            <td width="300"><input type="text" name="license1" value="<%if formsubmitted then Response.Write Request.Form("license1")%>"></td>
                          </tr>
                          <tr>
                            <td width="250">Which vehicle do you drive?</td>
                            <td width="300">
                              <select name="drive1">
                                <option value="1" <%if Request.Form("state")="1" then Response.Write "selected"%>>#1</option>
                                <option value="2" <%if Request.Form("state")="2" then Response.Write "selected"%>>#2</option>
                                <option value="3" <%if Request.Form("state")="3" then Response.Write "selected"%>>#3</option>
                                <option value="4" <%if Request.Form("state")="4" then Response.Write "selected"%>>#4</option>
                              </select>
                            </td>
                          </tr>
                          <tr>
                            <td colspan="2">
                              Please enter any tickets or accidents in the last 3 years:<br/>
                              <textarea name="record1" class="black" rows="5" cols="70"><%=NoTags(request.form("record1"))%></textarea>
                            </td>
                          </tr>
                          </table>
                          <br/>
                          <b>Driver #2</b><br/>
                          <table width="550" cellpadding="1" cellspacing="0" border="0" class="black" bgcolor="#EEECE7">
                          <tr>
                            <td width="250">Driver's Name</td>
                            <td width="300">
                              <input type="text" name="name2" value="<%if formsubmitted then Response.Write Request.Form("name2")%>"></td>
                          </tr>
                          <tr>
                            <td width="250">Date of Birth</td>
                            <td width="300"><input type="text" name="dob2" value="<%if formsubmitted then Response.Write Request.Form("dob2")%>"></td>
                          </tr>
                          <tr>
                            <td width="250">Driver's License #</td>
                            <td width="300"><input type="text" name="license2" value="<%if formsubmitted then Response.Write Request.Form("license2")%>"></td>
                          </tr>
                          <tr>
                            <td width="250">Which vehicle do you drive?</td>
                            <td width="300">
                              <select name="drive2">
                                <option value="1" <%if Request.Form("state")="1" then Response.Write "selected"%>>#1</option>
                                <option value="2" <%if Request.Form("state")="2" then Response.Write "selected"%>>#2</option>
                                <option value="3" <%if Request.Form("state")="3" then Response.Write "selected"%>>#3</option>
                                <option value="4" <%if Request.Form("state")="4" then Response.Write "selected"%>>#4</option>
                              </select>
                            </td>
                          </tr>
                          <tr>
                            <td colspan="2">
                              Please enter any tickets or accidents in the last 3 years:<br/>
                              <textarea name="record2" class="black" rows="5" cols="70"><%=NoTags(request.form("record1"))%></textarea>
                            </td>
                          </tr>
                          </table>
                          <br/>
                          <b>Driver #3</b><br/>
                          <table width="550" cellpadding="1" cellspacing="0" border="0" class="black">
                          <tr>
                            <td width="250">Driver's Name</td>
                            <td width="300">
                              <input type="text" name="name3" value="<%if formsubmitted then Response.Write Request.Form("name3")%>"></td>
                          </tr>
                          <tr>
                            <td width="250">Date of Birth</td>
                            <td width="300"><input type="text" name="dob3" value="<%if formsubmitted then Response.Write Request.Form("dob3")%>"></td>
                          </tr>
                          <tr>
                            <td width="250">Driver's License #</td>
                            <td width="300"><input type="text" name="license3" value="<%if formsubmitted then Response.Write Request.Form("license3")%>"></td>
                          </tr>
                          <tr>
                            <td width="250">Which vehicle do you drive?</td>
                            <td width="300">
                              <select name="drive3">
                                <option value="1" <%if Request.Form("state")="1" then Response.Write "selected"%>>#1</option>
                                <option value="2" <%if Request.Form("state")="2" then Response.Write "selected"%>>#2</option>
                                <option value="3" <%if Request.Form("state")="3" then Response.Write "selected"%>>#3</option>
                                <option value="4" <%if Request.Form("state")="4" then Response.Write "selected"%>>#4</option>
                              </select>
                            </td>
                          </tr>
                          <tr>
                            <td colspan="2">
                              Please enter any tickets or accidents in the last 3 years:<br/>
                              <textarea name="record3" class="black" rows="5" cols="70"><%=NoTags(request.form("record1"))%></textarea>
                            </td>
                          </tr>
                          </table>
                          <br/>
                          <b>Driver #4</b><br/>
                          <table width="550" cellpadding="1" cellspacing="0" border="0" class="black" bgcolor="#EEECE7">
                          <tr>
                            <td width="250">Driver's Name</td>
                            <td width="300">
                              <input type="text" name="name4" value="<%if formsubmitted then Response.Write Request.Form("name4")%>"></td>
                          </tr>
                          <tr>
                            <td width="250">Date of Birth</td>
                            <td width="300"><input type="text" name="dob4" value="<%if formsubmitted then Response.Write Request.Form("dob4")%>"></td>
                          </tr>
                          <tr>
                            <td width="250">Driver's License #</td>
                            <td width="300"><input type="text" name="license4" value="<%if formsubmitted then Response.Write Request.Form("license4")%>"></td>
                          </tr>
                          <tr>
                            <td width="250">Which vehicle do you drive?</td>
                            <td width="300">
                              <select name="drive4">
                                <option value="1" <%if Request.Form("state")="1" then Response.Write "selected"%>>#1</option>
                                <option value="2" <%if Request.Form("state")="2" then Response.Write "selected"%>>#2</option>
                                <option value="3" <%if Request.Form("state")="3" then Response.Write "selected"%>>#3</option>
                                <option value="4" <%if Request.Form("state")="4" then Response.Write "selected"%>>#4</option>
                              </select>
                            </td>
                          </tr>
                          <tr>
                            <td colspan="2">
                              Please enter any tickets or accidents in the last 3 years:<br/>
                              <textarea name="record4" class="black" rows="5" cols="70"><%=NoTags(request.form("record1"))%></textarea>
                            </td>
                          </tr>
                          </table>
                          <table width="550" cellpadding="1" cellspacing="0" border="0" class="black">
                          <tr>
                            <td colspan="2" height="10"><img src="/images/common/pixel_clear.gif" border="0" /></td>
                          </tr>
                          <tr>
                            <td colspan="2" height="2" bgcolor="#6DAA6D"><img src="/images/common/pixel_clear.gif" border="0" /></td>
                          </tr>
                          <tr>
                            <td colspan="2" height="10"><img src="/images/common/pixel_clear.gif" border="0" /></td>
                          </tr>
                          </table>
                          <b>Coverages</b><br/>
                          <br/>
                          <table width="550" cellpadding="1" cellspacing="0" border="0" class="black">
                          <tr>
                            <td width="275">Uninsured/Underinsured Motorist Coverages</td>
                            <td>
                              <select name="coverage">
                                <option value="20,000/40,000" <%if formsubmitted AND Request.Form("coverage")="20,000/40,000" then Response.Write "selected"%>>20,000/40,000</option>
                                <option value="25,000/50,000" <%if formsubmitted AND Request.Form("coverage")="25,000/50,000" then Response.Write "selected"%>>25,000/50,000</option>
                                <option value="50,000/100,000" <%if formsubmitted AND Request.Form("coverage")="50,000/100,000" then Response.Write "selected"%>>50,000/100,000</option>
                                <option value="100,000/100,000" <%if formsubmitted AND Request.Form("coverage")="100,000/100,000" then Response.Write "selected"%>>100,000/100,000</option>
                                <option value="100,000/200,000" <%if formsubmitted AND Request.Form("coverage")="100,000/200,000" then Response.Write "selected"%>>100,000/200,000</option>
                                <option value="100,000/300,000" <%if (formsubmitted AND Request.Form("coverage")="100,000/300,000") or NOT formsubmitted then Response.Write "selected"%>>100,000/300,000</option>
                                <option value="100,000/500,000" <%if formsubmitted AND Request.Form("coverage")="100,000/500,000" then Response.Write "selected"%>>100,000/500,000</option>
                                <option value="250,000/500,000" <%if formsubmitted AND Request.Form("coverage")="250,000/500,000" then Response.Write "selected"%>>250,000/500,000</option>
                                <option value="300,000/300,000" <%if formsubmitted AND Request.Form("coverage")="300,000/300,000" then Response.Write "selected"%>>300,000/300,000</option>
                                <option value="300,000/500,000" <%if formsubmitted AND Request.Form("coverage")="300,000/500,000" then Response.Write "selected"%>>300,000/500,000</option>
                                <option value="500,000/500,000" <%if formsubmitted AND Request.Form("coverage")="500,000/500,000" then Response.Write "selected"%>>500,000/500,000</option>
                              </select>
                            </td>
                          </tr>
                          </table>
                          <table width="550" cellpadding="1" cellspacing="0" border="0" class="black">
                          <tr>
                            <td width="275">Medical Payments</td>
                            <td>
                              <select name="medical">
                                <option value="500" <%if formsubmitted AND Request.Form("medical")="500" then Response.Write "selected"%>>500</option>
                                <option value="1000" <%if formsubmitted AND Request.Form("medical")="1000" then Response.Write "selected"%>>1,000</option>
                                <option value="2000" <%if formsubmitted AND Request.Form("medical")="2000" then Response.Write "selected"%>>2,000</option>
                                <option value="5000" <%if (formsubmitted AND Request.Form("medical")="5000") or NOT formsubmitted then Response.Write "selected"%>>5,000</option>
                                <option value="10,000" <%if formsubmitted AND Request.Form("medical")="10,000" then Response.Write "selected"%>>10,000</option>
                              </select>
                            </td>
                          </tr>
                          </table>
                          <br/>
                          <b>Comprehensive/Other Than Collision</b><br/>
                          <table width="550" cellpadding="1" cellspacing="0" border="0" class="black">
                          <tr>
                            <td width="275">Vehicle #1 Deductible</td>
                            <td>
                              <select name="deductible1">
                                <option value="n/a" <%if formsubmitted AND Request.Form("deductible1")="n/a" then Response.Write "selected"%>>n/a</option>
                                <option value="$100" <%if formsubmitted AND Request.Form("deductible1")="$100" then Response.Write "selected"%>>$100</option>
                                <option value="$150" <%if formsubmitted AND Request.Form("deductible1")="$150" then Response.Write "selected"%>>$150</option>
                                <option value="$200" <%if (formsubmitted AND Request.Form("deductible1")="$200") OR NOT formsubmitted then Response.Write "selected"%>>$200</option>
                                <option value="$250" <%if formsubmitted AND Request.Form("deductible1")="$250" then Response.Write "selected"%>>$250</option>
                                <option value="$500" <%if formsubmitted AND Request.Form("deductible1")="$500" then Response.Write "selected"%>>$500</option>
                                <option value="$1,000" <%if formsubmitted AND Request.Form("deductible1")="$1,000" then Response.Write "selected"%>>$1,000</option>
                              </select>
                            </td>
                          </tr>
                          <tr>
                            <td width="275">Vehicle #2 Deductible</td>
                            <td>
                              <select name="deductible2">
                                <option value="n/a" <%if NOT formsubmitted AND Request.Form("deductible2")="n/a" then Response.Write "selected"%>>n/a</option>
                                <option value="$100" <%if formsubmitted AND Request.Form("deductible2")="$100" then Response.Write "selected"%>>$100</option>
                                <option value="$150" <%if formsubmitted AND Request.Form("deductible2")="$150" then Response.Write "selected"%>>$150</option>
                                <option value="$200" <%if formsubmitted AND Request.Form("deductible2")="$200" then Response.Write "selected"%>>$200</option>
                                <option value="$250" <%if formsubmitted AND Request.Form("deductible2")="$250" then Response.Write "selected"%>>$250</option>
                                <option value="$500" <%if formsubmitted AND Request.Form("deductible2")="$500" then Response.Write "selected"%>>$500</option>
                                <option value="$1,000" <%if formsubmitted AND Request.Form("deductible2")="$1,000" then Response.Write "selected"%>>$1,000</option>
                              </select>
                            </td>
                          </tr>
                          <tr>
                            <td width="275">Vehicle #3 Deductible</td>
                            <td>
                              <select name="deductible3">
                                <option value="n/a" <%if NOT formsubmitted AND Request.Form("deductible2")="n/a" then Response.Write "selected"%>>n/a</option>
                                <option value="$100" <%if formsubmitted AND Request.Form("deductible2")="$100" then Response.Write "selected"%>>$100</option>
                                <option value="$150" <%if formsubmitted AND Request.Form("deductible2")="$150" then Response.Write "selected"%>>$150</option>
                                <option value="$200" <%if formsubmitted AND Request.Form("deductible2")="$200" then Response.Write "selected"%>>$200</option>
                                <option value="$250" <%if formsubmitted AND Request.Form("deductible2")="$250" then Response.Write "selected"%>>$250</option>
                                <option value="$500" <%if formsubmitted AND Request.Form("deductible2")="$500" then Response.Write "selected"%>>$500</option>
                                <option value="$1,000" <%if formsubmitted AND Request.Form("deductible2")="$1,000" then Response.Write "selected"%>>$1,000</option>
                              </select>
                            </td>
                          </tr>
                          <tr>
                            <td width="275">Vehicle #4 Deductible</td>
                            <td>
                              <select name="deductible4">
                                <option value="n/a" <%if NOT formsubmitted OR Request.Form("deductible2")="n/a" then Response.Write "selected"%>>n/a</option>
                                <option value="$100" <%if formsubmitted AND Request.Form("deductible2")="$100" then Response.Write "selected"%>>$100</option>
                                <option value="$150" <%if formsubmitted AND Request.Form("deductible2")="$150" then Response.Write "selected"%>>$150</option>
                                <option value="$200" <%if formsubmitted AND Request.Form("deductible2")="$200" then Response.Write "selected"%>>$200</option>
                                <option value="$250" <%if formsubmitted AND Request.Form("deductible2")="$250" then Response.Write "selected"%>>$250</option>
                                <option value="$500" <%if formsubmitted AND Request.Form("deductible2")="$500" then Response.Write "selected"%>>$500</option>
                                <option value="$1,000" <%if formsubmitted AND Request.Form("deductible2")="$1,000" then Response.Write "selected"%>>$1,000</option>
                              </select>
                            </td>
                          </tr>
                          </table>
                          <br/>
                          <b>Collision Deductible</b><br/>
                          <table width="550" cellpadding="1" cellspacing="0" border="0" class="black">
                          <tr>
                            <td width="275">Vehicle #1</td>
                            <td>
                              <select name="collision1">
                                <option value="n/a" <%if formsubmitted AND Request.Form("collision1")="n/a" then Response.Write "selected"%>>n/a</option>
                                <option value="$100" <%if formsubmitted AND Request.Form("collision1")="$100" then Response.Write "selected"%>>$100</option>
                                <option value="$150" <%if formsubmitted AND Request.Form("collision1")="$150" then Response.Write "selected"%>>$150</option>
                                <option value="$200" <%if formsubmitted AND Request.Form("collision1")="$200" then Response.Write "selected"%>>$200</option>
                                <option value="$250" <%if formsubmitted AND Request.Form("collision1")="$250" then Response.Write "selected"%>>$250</option>
                                <option value="$500" <%if (formsubmitted AND Request.Form("collision1")="$500") OR NOT formsubmitted  then Response.Write "selected"%>>$500</option>
                                <option value="$1,000" <%if formsubmitted AND Request.Form("collision1")="$1,000" then Response.Write "selected"%>>$1,000</option>
                              </select>
                            </td>
                          </tr>
                          <tr>
                            <td width="275">Vehicle #2</td>
                            <td>
                              <select name="collision2">
                                <option value="n/a" <%if NOT formsubmitted AND Request.Form("collision2")="n/a" then Response.Write "selected"%>>n/a</option>
                                <option value="$100" <%if formsubmitted AND Request.Form("collision2")="$100" then Response.Write "selected"%>>$100</option>
                                <option value="$150" <%if formsubmitted AND Request.Form("collision2")="$150" then Response.Write "selected"%>>$150</option>
                                <option value="$200" <%if formsubmitted AND Request.Form("collision2")="$200" then Response.Write "selected"%>>$200</option>
                                <option value="$250" <%if formsubmitted AND Request.Form("collision2")="$250" then Response.Write "selected"%>>$250</option>
                                <option value="$500" <%if formsubmitted AND Request.Form("collision2")="$500" then Response.Write "selected"%>>$500</option>
                                <option value="$1,000" <%if formsubmitted AND Request.Form("collision2")="$1,000" then Response.Write "selected"%>>$1,000</option>
                              </select>
                            </td>
                          </tr>
                          <tr>
                            <td width="275">Vehicle #3</td>
                            <td>
                              <select name="collision3">
                                <option value="n/a" <%if NOT formsubmitted AND Request.Form("collision3")="n/a" then Response.Write "selected"%>>n/a</option>
                                <option value="$100" <%if formsubmitted AND Request.Form("collision3")="$100" then Response.Write "selected"%>>$100</option>
                                <option value="$150" <%if formsubmitted AND Request.Form("collision3")="$150" then Response.Write "selected"%>>$150</option>
                                <option value="$200" <%if formsubmitted AND Request.Form("collision3")="$200" then Response.Write "selected"%>>$200</option>
                                <option value="$250" <%if formsubmitted AND Request.Form("collision3")="$250" then Response.Write "selected"%>>$250</option>
                                <option value="$500" <%if formsubmitted AND Request.Form("collision3")="$500" then Response.Write "selected"%>>$500</option>
                                <option value="$1,000" <%if formsubmitted AND Request.Form("collision3")="$1,000" then Response.Write "selected"%>>$1,000</option>
                              </select>
                            </td>
                          </tr>
                          <tr>
                            <td width="275">Vehicle #4</td>
                            <td>
                              <select name="collision4">
                                <option value="n/a" <%if NOT formsubmitted AND Request.Form("collision4")="n/a" then Response.Write "selected"%>>n/a</option>
                                <option value="$100" <%if formsubmitted AND Request.Form("collision4")="$100" then Response.Write "selected"%>>$100</option>
                                <option value="$150" <%if formsubmitted AND Request.Form("collision4")="$150" then Response.Write "selected"%>>$150</option>
                                <option value="$200" <%if formsubmitted AND Request.Form("collision4")="$200" then Response.Write "selected"%>>$200</option>
                                <option value="$250" <%if formsubmitted AND Request.Form("collision4")="$250" then Response.Write "selected"%>>$250</option>
                                <option value="$500" <%if formsubmitted AND Request.Form("collision4")="$500" then Response.Write "selected"%>>$500</option>
                                <option value="$1,000" <%if formsubmitted AND Request.Form("collision4")="$1,000" then Response.Write "selected"%>>$1,000</option>
                              </select>
                            </td>
                          </tr>
                          </table>
                          <br/>
                          <table width="550" cellpadding="1" cellspacing="0" border="0" class="black">
                          <tr>
                            <td width="275">Towing Coverage</td>
                            <td>
                              <select name="towing">
                                <option value="Yes" <%if Request.Form("towing")="1" then Response.Write "selected"%>>Yes</option>
                                <option value="No" <%if Request.Form("towing")="2" then Response.Write "selected"%>>No</option>
                              </select>
                            </td>
                          </tr>
                          <tr>
                            <td width="275">Rental Reimbursement Coverage</td>
                            <td>
                              <select name="rental">
                                <option value="Yes" <%if Request.Form("rental")="1" then Response.Write "selected"%>>Yes</option>
                                <option value="No" <%if Request.Form("rental")="2" then Response.Write "selected"%>>No</option>
                              </select>
                            </td>
                          </tr>
                          </table>
                          <br/>
                          <table width="550" cellpadding="1" cellspacing="0" border="0" class="black">
                          <tr>
                            <td width="200">How would you like us to respond</td>
                            <td width="250">
                              <select name="respond">
                                <option value="Phone">Phone</option>
                                <option value="Email">Email</option>
                                <option value="Fax">Fax</option>
                              </select>
                            </td>
                          </tr>
                          <tr>
                            <td colspan="2" height="10"><img src="/images/common/pixel_clear.gif" border="0" /></td>
                          </tr>
                          <tr>
                            <td colspan="2">
                              If you have any other questions or comments concerning your free auto insurance quote, please enter them here:<br/>
                              <textarea name="comments" class="black" rows="5" cols="80"><%=NoTags(request.form("comments"))%></textarea>
                            </td>
                          </tr>
                          </table>
                          <br/>
                          <input type=hidden name=formsubmitted value=1>
                          <input type=submit value=" SUBMIT QUOTE ">
                          </form>
                          <br/>
                          <br/>
                        <!-- content end -->
                        </td>
                    </tr>
                    <tr>
                        <td nowrap><img src="/images/common/pixel_clear.gif" width=1 height=13></td>
                        <td valign=top nowrap width=33><img src="/images/misc5.gif" width=33 height=12></td>
                        <td valign=top width="100%" background="/images/bg3.gif"><img src="/images/common/pixel_clear.gif" width=550 height=13></td>
                    </tr>
                    <tr><td colspan=3 align=right>
                        <!--#include virtual="/include/footerinfo.htm"-->
                    </td></tr>
                </table>
            </td>
            <td bgcolor="#333333"><img src="pixel_clear.gif" width=1 height=1></td>
            <td bgcolor="#EEEEEE" width="50%"><img src="pixel_clear.gif" width=1 height=1></td>
        </tr></table>
        
    </body>
    
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