<%@ include file="header.html" %> <%@ import = "javax.mail.*,javax.mail.internet.*,javax.activation.*,java.net.InetAddress" %> <% boolean shouldShowFirstForm = true; String param_info[][] = { {"firstName", "First Name", "required", "You must enter your First Name"}, {"lastName", "Last Name", "required", "You must enter your Last Name"}, {"address1", "Address 1", "required", "You must enter your Address"}, {"address2", "Address 2", "not required", ""}, {"city", "City", "required", "You must enter your City"}, {"state", "State", "required", "You must enter your State"}, {"zip", "Zip Code", "required", "You must enter your Zip"}, {"phone", "Phone", "required", "You must enter your Phone Number"}, {"fax", "Fax", "required", ""}, {"email", "E-Mail", "required", "You must enter your E-Mail"}, {"amountinsurance", "Amount of Insurance", "required", "You must enter the amount of insurance"}, {"deductible", "Deductible", "not required", ""}, {"typedwell", "Type of Dwelling", "not required", ""}, {"dwelluse", "Dwelling Use", "not required", ""}, {"liability", "Liability", "not required", ""}, {"medpay", "Medical Payments", "not required", ""}, {"propaddress", "Property Address", "not required", ""}, {"propcity", "Property City", "not required", ""}, {"propstate", "Property Sate", "not required", ""}, {"propzip", "Property Zip", "not required", ""}, {"propcounty", "Property County", "not required", ""}, {"structureType", "Type of Structure", "not required", ""}, {"StructureTypeOtherDefined", "Other Defined", "not required", ""}, {"yearBuilt", "Year Built", "not required", ""}, {"squareFeet", "Square Feet", "not required", ""}, {"numberFamilies", "Number of Families", "required", "You must enter the number of families"}, {"swimmingPool", "Swimming Pool", "not required", ""}, {"distanceHydrant", "Distance to Fire Hydrant", "not required", ""}, {"distanceFireStation", "Distance to Fire Station", "not required", ""}, {"centralFireSystem", "Central Fire System", "not required", ""}, {"centralSmokeSystem", "Central Smoke System", "not required", ""}, {"centralBurglarSystem", "Central Burglar System", "not required", ""}, {"wiring", "Wiring Update", "not required", ""}, {"wiringYear", "Wiring Update Year", "not required", ""}, {"plumbing", "Plumbing Update", "not required", ""}, {"plumbingYear", "Plumbing Update Year", "not required", ""}, {"heating", "Heating Update", "not required", ""}, {"heatingYear", "Heating Update Year", "not required", ""}, {"roofing", "Roof Update", "not required", ""}, {"roofingYear", "Roof Update Year", "not required", ""}, {"claiminfo", "Claim Information", "not required", ""}, {"remarks", "Remarks", "not required", ""}, }; if (request.getParameter("op") != null) { String errmsg = ""; for(int i = 0; i < param_info.length; i++) { if (param_info[i][2] == "required") { if ((request.getParameter(param_info[i][0]) == null) || (request.getParameter(param_info[i][0]).length() == 0)) { errmsg = errmsg.concat("

" + param_info[i][3]); } } } if (errmsg == "") { shouldShowFirstForm = false; } else { out.println(""); out.println(" "); out.println(" "); out.println(" "); out.println("

Sorry Your Application Is Incomplete

We are missing some required information from the form you submitted. The following is a list of corrections you must make before we can process your application. Please make the corrections to the form below and resend it.

"); out.println("

"); out.println(errmsg); out.println(" "); out.println("

"); out.println("

"); } } %> <% if (shouldShowFirstForm == true) { %>

Homeowners/Renters Quote Request:

General Information:
Contact Name: (First, Last)
Address

City/State/Zip
Phone		Fax
E-Mail Address

Coverages/Limits of Liability:
Amount of Insurance:	$	Deductible:
Type of Dwelling:
Dwelling Use:
Liability:		Medical Payments:
	Address of Property if Different from Above:
Address:
City/State/Zip
County:

Rating Information:
Frame	Masonry	Masonry Veneer
Other
Year Built:		Square Feet:
Number of Families:		Swimming Pool:	YesNo

Protection Information:
Distance To Hydrant:		Distance To Fire Station:
Central Fire System:	YesNo
Central Smoke System:	YesNo
Central Burglar System:	YesNo

Renovations:
Wiring	PartialComplete
Plumbing	PartialComplete
Heating	PartialComplete
Roofing	PartialComplete

Claim Information:
If you have any claims within the last 5 years, please explain them below:

Remarks:

<% } else { %> <% String mailhost = "couchnt03.couchbraunsdorf.com"; String msgfrom = request.getParameter("firstName") + " " + request.getParameter("lastName") + " <" + request.getParameter("email") + ">"; String msgto = "info@couchbraunsdorf.com"; String msgcc = null; String msgbcc = "info@couchbraunsdorf.com"; String msgsubject = "Home Application"; StringBuffer msgtext = new StringBuffer(); int maxlength = 0; for(int i = 0; i < param_info.length; i++) { if ((request.getParameter(param_info[i][0]) != null) && (request.getParameter(param_info[i][0]).length() != 0) && (param_info[i][1].length() > maxlength)) {maxlength = param_info[i][1].length();} } for(int i = 0; i < param_info.length; i++) { if ((request.getParameter(param_info[i][0]) != null) && (request.getParameter(param_info[i][0]).length() != 0)) { msgtext.append(param_info[i][1]); for(int j = 0; j < maxlength - param_info[i][1].length(); j++) {msgtext.append(" ");} msgtext.append(" - " + request.getParameter(param_info[i][0]) + "\n"); } } try { Properties props = System.getProperties(); if (mailhost != null) { props.put("mail.smtp.host", mailhost); } Session session = javax.mail.Session.getDefaultInstance(props, null); MimeMessage msg = new MimeMessage(session); msg.setFrom(new InternetAddress(msgfrom)); msg.setRecipients(Message.RecipientType.TO, InternetAddress.parse(msgto, false)); if (msgcc != null) { msg.setRecipients(Message.RecipientType.CC, InternetAddress.parse(msgcc, false)); } if (msgbcc != null) { msg.setRecipients(Message.RecipientType.BCC, InternetAddress.parse(msgbcc, false)); } msg.setSubject(msgsubject); msg.setText("A " + msgsubject + " was recieved on the Couch Braunsdorf Insurance Web site:\n\n" + msgtext.toString()); msg.setHeader("X-Mailer", "Revolutionary Systems"); msg.setSentDate(new Date()); Transport.send(msg); } catch (Exception e) { } msgfrom = "Couch Braunsdorf Title Insurance "; msgto = request.getParameter("email"); msgcc = null; msgbcc = null; msgsubject = "Home Insurance Application"; try { Properties props = System.getProperties(); if (mailhost != null) { props.put("mail.smtp.host", mailhost); } Session session = javax.mail.Session.getDefaultInstance(props, null); MimeMessage msg = new MimeMessage(session); msg.setFrom(new InternetAddress(msgfrom)); msg.setRecipients(Message.RecipientType.TO, InternetAddress.parse(msgto, false)); if (msgcc != null) { msg.setRecipients(Message.RecipientType.CC, InternetAddress.parse(msgcc, false)); } if (msgbcc != null) { msg.setRecipients(Message.RecipientType.BCC, InternetAddress.parse(msgbcc, false)); } msg.setSubject(msgsubject); msg.setText("Thank You for your recent request. For your records, here is the information you submitted\n\n" + msgtext.toString()); msg.setHeader("X-Mailer", "Revolutionary Systems"); msg.setSentDate(new Date()); Transport.send(msg); } catch (Exception e) { } %>

Thank You

You will be contacted shortly regarding your application by a representative within one business day. You will also shortly receive a message by e-mail confirm the contents of your application.

<% } %><%@ include file="footer.html" %>