$errorcount = 0; if($submit) { if( !$name ) { $nameerror = 1; $errorcount++; } if( !$address ) { $addresserror = 1; $errorcount++; } if( !$city ) { $cityerror = 1; $errorcount++; } if( !$zip ) { $ziperror = 1; $errorcount++; } if( !$zip ) { $ziperror = 1; $errorcount++; } if( !$phone ) { $phoneerror = 1; $errorcount++; } if( !$email ) { $emailerror = 1; $errorcount++; } if( !$gender ) { $gendererror = 1; $errorcount++; } if( $dobmo == -1 ) { $doberror = 1; $errorcount++; } if( $dobday == -1 ) { $doberror = 1; $errorcount++; } if( !$dobyear ) { $doberror = 1; $errorcount++; } if( !$tobacco ) { $tobaccoerror = 1; $errorcount++; } if( !$annualincome ) { $annualincomeerror = 1; $errorcount++; } if( !$occupation ) { $occupationerror = 1; $errorcount++; } if( !$workduties ) { $workdutieserror = 1; $errorcount++; } if( !$existingcoverage ) { $existingcoverageerror = 1; $errorcount++; } if( !existingcoveragedesc && $existingcoverage == "Yes" ) { $existingcoverageerror = 1; $errorcount++; } if( !$healthprobs ) { $healthprobserror = 1; $errorcount++; } if( !$monthlybenefits ) { $monthlybenefitserror = 1; $errorcount++; } if( !$elimperiod ) { $elimperioderror = 1; $errorcount++; } if( !$benefitperiod ) { $benefitperioderror = 1; $errorcount++; } if( !$quoteby ) { $quotebyerror = 1; $errorcount++; } if( $quoteby == "E-mail") $by = "E-mail"; if( $quoteby == "Fax") $by = "Fax"; if( $quoteby == "Phone") $by = "Phone"; if( $quoteby == "Fax" && !$fax) { $faxerror = 1; $errorcount++; } if( $errorcount == 0 ) { $message = "\n"; $message = $message."The following request for an INDIVIDUAL DISABILITY quote was recieved \n on the Globalindemnity.com web site. Please respond quickly. \n \n"; $message = $message."Name: ".$name."\n\n"; $message = $message."Address: ".$address.", ".$city.", ".$zip."\n\n"; $message = $message."Phone: ".$phone."\n\n"; $message = $message."E-mail: ".$email."\n\n"; if ( $fax ) $message = $message."Fax: ".$fax."\n\n"; $message = $message."Gender: ".$gender."\n\n"; $message = $message."DOB: ".$dobmo."/".$dobday."/".$dobyear."\n\n"; $message = $message."Tobacco use: ".$tobacco."\n\n"; $message = $message."Annual income: $".$annualincome."\n\n"; $message = $message."Occupation: ".$occupation."\n\n"; $message = $message."Workduties: ".$workduties."\n\n"; $message = $message."Existing coverage: ".$existingcoverage."\n\n"; if ( $existingcoverage ) $message = $message."Existing coverage description: ".$existingcoveragedesc."\n\n"; $message = $message."Current health problems: ".$healthprobs."\n\n"; $message = $message."Monthly benefits desired: $".$monthlybenefits."\n\n"; $message = $message."Elimination Period: ".$elimperiod."\n\n"; $message = $message."Benefit Period: ".$benefitperiod."\n\n"; if (!is_array($QuoteOptions)) $QuoteOptions[0] = ""; else { $message = $message."Quote options requested: "; for ( reset($QuoteOptions); current($QuoteOptions); next($QuoteOptions) ) { $message = $message.", ".current($QuoteOptions); } $message = $message."\n\n"; } $message = $message."Provide quote by: ".$quoteby."\n\n"; $message = $message."Contact time (if by phone): ".$contacttime."\n\n"; mail("tszymanski@globalindemins.com, chruby@globalindemins.com, dgraham@obsg.com", "URGENT: Web quote request", $message); header("Location: qqdone.php3?t=Disability&by=".$by); } } ?>