Your IP : 18.116.89.70
<?php
include('data.php');
$page_title="Contact Us";
$sub_page_title=$sub_title_contact;
$pageMetaKeywords=$page_keys_contact;
$pageMetaDescription=$page_descrip_contact;
include('header.php');
?>
<br />
<h3>Please continue to fill out the form!</h3>
<p> Please let us know a little bit more about you so that we may better suite your needs. <strong><? echo $businessName; ?></strong> is dedicated to helping <strong>you</strong>. </p>
<p>We look forward to assisting you with the application process and consider it an honor to be your agency.</p>
<form name="short-form" method="post" action="form_Captcha.php" id="short-form" class="form-horizontal">
<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 General Request" />
<div class="well">
<div class="row">
<div class="field">
<label class="stack">First Name</label>
<input name="firstname" type="text" class="input-large required" id="firstname" value="<?php echo $firstName; ?>" required>
</div>
<div class="field">
<label class="stack">Last Name</label>
<input name="lastname" type="text" class="input-large required" id="lastname" value="<?php echo $lastName; ?>" required>
</div>
<div class="field">
<label class="stack">Street Address</label>
<input name="Address" type="text" class="input-xlarge" id="Address">
</div>
</div>
<div class="clear"></div>
<div class="row">
<div class="field">
<label class="stack">City</label>
<input name="City" type="text" class="input-medium" id="City">
</div>
<div class="field">
<label class="stack">State</label>
<select name="state" id="state" class="input-medium">
<option selected="selected">---</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="FL">Florida</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>
</div>
<div class="field">
<label class="stack">Zip</label>
<input name="Zip" type="text" class="input-small" id="Zip">
</div>
</div>
<div class="clear"></div>
</div>
<div class="well">
<div class="row">
<div class="field">
<label class="stack">Phone</label>
<input name="Phone" type="text" class="input-medium required" id="Phone" value="<? echo $_POST['Phone']; ?>" required>
</div>
<div class="field">
<label class="stack">Email</label>
<input name="Email" type="text" class="input-medium required" id="Email" value="<? echo $_POST['Email']; ?>" required>
</div>
</div>
<div class="clear"></div>
</div>
<div class="well">
<div class="row">
<div class="field">
<label class="stack">Heated Square Footage</label>
<input name="Phone" type="text" class="input-medium required" id="Phone" value="<? echo $_POST['Phone']; ?>">
</div>
<div class="field">
<label class="stack">Current Home Insurance Premium</label>
<input name="Current Home Insurance Premium" type="text" class="input-medium" id="Home_Insurance_Premium">
</div>
<div class="field">
<label class="stack">Property Occupied By</label>
<select name="Property Occupied By" id="prop_occup_by" class="input-medium">
<option selected="selected">---</option>
<option value="Tenant">Tenant</option>
<option value="Owner">Owner</option>
</select>
</div>
</div>
<div class="clear"></div>
</div>
<div class="well">
<fieldset>
<div class="row">
<div class="field">
<label class="stack">Leave us a Message</label>
<textarea class="input-xxlarge" name="Comments" id="Comments" rows="4"><? echo $_POST['Comments']; ?></textarea>
</div>
</div>
<div class="row">
<script type="text/javascript"> var RecaptchaOptions = { theme : 'clean' }; </script>
<?
require_once('recaptchalib.php');
$publickey = "6Le1acYSAAAAAO342L2Pw0sUsPGtRNDXrwtH0NK5"; // you got this from the signup page
echo recaptcha_get_html($publickey);
?>
</div>
</fieldset>
<div class="clear"></div>
</div> <!--{ end well }-->
<div style="PADDING-LEFT:20px;">
<button type="submit" id="submit" class="btn btn-inverse" value="Send Form">Send Form</button>
<button type="reset" class="btn">Cancel</button>
</div>
</form>
<br />
<?php include('footer-index.php'); ?>