Your IP : 3.136.27.210
<?php include("data.php");?>
<?php $pagePhoto="slider_1.jpg";
$page_title='Compare Rates Now | Lakeland, Florida | Compare Florida Rates';
$sub_page_title='Compare Rates';
$pagePicture="";
$pageMetaKeyword=""; //Page Keyword List
$pageMetaDescription=""; //Page Meta Description List
session_start();
$firstName = $_POST['firstname'];
$zipCode = $_POST['zip'];
?>
<?php include("header.php");?>
<div class="hero-aboutus">
<div class="container">
<div class="row">
<div class="col-xl-12 col-md-12">
<div class="main-content">
<h1><u>Compare Rates Quote Form</u></h1>
<form name="short-form" action="success.php" method="post" id="short-form" class="form-elem">
<input type="hidden" name="toEmail" value="<?PHP echo $mainEmail;?>" />
<input type="hidden" name="requestType" value="request for contact" />
<input type="hidden" name="mailSubject" value="Online SEMCAT Quote Request" />
<table>
<tbody>
<tr>
<td>First Name</td>
<?if(isset($_POST['firstname'])){?>
<td><input type="text" name ="firstname" id="firstname" value="<?php echo $firstName; ?>" required/></td>
<?}else{?>
<td><input type="text" name="firstname" id="firstname" required/></td>
<?}?>
</tr>
<tr>
<td>Last Name</td>
<td><input type="text" name="lastname" id="lastname" required/></td>
</tr>
<tr>
<td>Email</td>
<td><input type="text" name="email" id="email" required/></td>
</tr>
<tr>
<tr>
<td>Phone</td>
<td><input type="text" name="phone" id="phone" required/></td>
</tr>
<tr>
<td>City</td>
<td><input type="text" name="city" id="city" /></td>
</tr>
<tr>
<td>State</td>
<td>
<select name="state" id="state" class="input-medium">
<option selected="FL">Florida</option>
<option value="AL">Alabama</option> <option value="AK">Alaska</option> <option value="AZ">Arizona</option>
<option value="AR">Arkansas</option> <option value="CA">California</option> <option value="CO">Colorado</option>
<option value="CT">Connecticut</option> <option value="DE">Delaware</option> <option value="DC">Dist of Columbia</option>
<option value="GA">Georgia</option> <option value="HI">Hawaii</option>
<option value="ID">Idaho</option> <option value="IL">Illinois</option> <option value="IN">Indiana</option>
<option value="IA">Iowa</option> <option value="KS">Kansas</option> <option value="KY">Kentucky</option>
<option value="LA">Louisiana</option> <option value="ME">Maine</option> <option value="MD">Maryland</option>
<option value="MA">Massachusetts</option> <option value="MI">Michigan</option> <option value="MN">Minnesota</option>
<option value="MS">Mississippi</option> <option value="MO">Missouri</option> <option value="MT">Montana</option>
<option value="NE">Nebraska</option> <option value="NV">Nevada</option> <option value="NH">New Hampshire</option>
<option value="NJ">New Jersey</option> <option value="NM">New Mexico</option> <option value="NY">New York</option>
<option value="NC">North Carolina</option> <option value="ND">North Dakota</option> <option value="OH">Ohio</option>
<option value="OK">Oklahoma</option> <option value="OR">Oregon</option> <option value="PA">Pennsylvania</option>
<option value="RI">Rhode Island</option> <option value="SC">South Carolina</option> <option value="SD">South Dakota</option>
<option value="TN">Tennessee</option> <option value="TX">Texas</option> <option value="UT">Utah</option>
<option value="VT">Vermont</option> <option value="VA">Virginia</option> <option value="WA">Washington</option>
<option value="WV">West Virginia</option> <option value="WI">Wisconsin</option> <option value="WY">Wyoming</option>
</select>
</td>
</tr>
<tr>
<td>Zip</td>
<?if(isset($_POST['zip'])){?>
<td><input type="text" name = "zip" value="<?php echo $zipCode; ?>"/></td>
<?}else{?>
<td><input type="text" name="zip" /></td>
<?}?>
</tr>
<tr>
<td>Property Address To Insure</td>
<td><input type="text" name="address_to_insure" required/></td>
</tr>
<tr>
<td>Approximate Age of Roof (number of years only)</td>
<td><input type="text" name="approximate_roof_age" required/></td>
</tr>
<tr>
<td>Have you had any claims other than Hurricane in the last 3 years?</td>
<td><select name="hurricane_in_last_3" required><option>Y</option><option>N</option>
</tr>
<tr>
<td>Dwelling Coverage Amount</td>
<td><input type="text" name="cov_a" /></td>
</tr>
<tr>
<td>Year Built</td>
<td><input type="text" name="year_built" /></td>
</tr>
<tr>
<td>Construction Type</td>
<td><select name="construction_type"><option value="M">Masonry</option><option value="F">Frame</option></td>
</tr>
<tr>
<td>Replacement Cost On Contents</td>
<td><select name="pp_repl_cost"><option>Y</option><option>N</option>
<tr>
<tr>
<td>New roof Since 2001</td>
<td><select name="roof_after_2001"><option>Y</option><option>N</option>
</tr>
<tr>
<td></td>
<tr>
<td> <label for="verification" class="stack">Enter the following number <img src="recaptcha-image.php" /></label></td>
<td>
<input type="text" name="verification" id="contactVerification" class="input-medium"> </td>
</td>
</tr>
</tr>
<td></td>
<td><button class="btn btn-primary" type="submit" value="Get Instant Quotes"/>GET INSTANT QUOTES</button></td>
</tr>
</tbody>
</table>
</form>
</div>
</div>
</div>
</div>
</div>
<?php include("footer.php"); ?>