<% dim objSecure dim objConn dim objRS dim strSQL dim strSiteTitle dim strSiteDomain dim objMailer dim strGroupQuoteEmail dim strCmd dim strBody dim intA dim arrEmailAddress dim strCompanyName dim strAddress dim strCity dim strState dim strZip dim strGroupContact dim strGroupPhone dim strGroupEmail dim strNatureBusiness dim strCurrentCarrier dim strHourlyMinimum dim strName1 dim strGender1 dim strDOB1 dim strDependentStatus1 dim strWaivingMedical1 dim strHoursPerWeek1 dim strName2 dim strGender2 dim strDOB2 dim strDependentStatus2 dim strWaivingMedical2 dim strHoursPerWeek2 dim strName3 dim strGender3 dim strDOB3 dim strDependentStatus3 dim strWaivingMedical3 dim strHoursPerWeek3 dim strName4 dim strGender4 dim strDOB4 dim strDependentStatus4 dim strWaivingMedical4 dim strHoursPerWeek4 dim strName5 dim strGender5 dim strDOB5 dim strDependentStatus5 dim strWaivingMedical5 dim strHoursPerWeek5 dim strName6 dim strGender6 dim strDOB6 dim strDependentStatus6 dim strWaivingMedical6 dim strHoursPerWeek6 dim strName7 dim strGender7 dim strDOB7 dim strDependentStatus7 dim strWaivingMedical7 dim strHoursPerWeek7 dim strName8 dim strGender8 dim strDOB8 dim strDependentStatus8 dim strWaivingMedical8 dim strHoursPerWeek8 dim strName9 dim strGender9 dim strDOB9 dim strDependentStatus9 dim strWaivingMedical9 dim strHoursPerWeek9 dim strName10 dim strGender10 dim strDOB10 dim strDependentStatus10 dim strWaivingMedical10 dim strHoursPerWeek10 dim strName11 dim strGender11 dim strDOB11 dim strDependentStatus11 dim strWaivingMedical11 dim strHoursPerWeek11 dim strName12 dim strGender12 dim strDOB12 dim strDependentStatus12 dim strWaivingMedical12 dim strHoursPerWeek12 dim strName13 dim strGender13 dim strDOB13 dim strDependentStatus13 dim strWaivingMedical13 dim strHoursPerWeek13 dim strName14 dim strGender14 dim strDOB14 dim strDependentStatus14 dim strWaivingMedical14 dim strHoursPerWeek14 dim strName15 dim strGender15 dim strDOB15 dim strDependentStatus15 dim strWaivingMedical15 dim strHoursPerWeek15 dim strName16 dim strGender16 dim strDOB16 dim strDependentStatus16 dim strWaivingMedical16 dim strHoursPerWeek16 dim strName17 dim strGender17 dim strDOB17 dim strDependentStatus17 dim strWaivingMedical17 dim strHoursPerWeek17 dim strName18 dim strGender18 dim strDOB18 dim strDependentStatus18 dim strWaivingMedical18 dim strHoursPerWeek18 dim strName19 dim strGender19 dim strDOB19 dim strDependentStatus19 dim strWaivingMedical19 dim strHoursPerWeek19 dim strName20 dim strGender20 dim strDOB20 dim strDependentStatus20 dim strWaivingMedical20 dim strHoursPerWeek20 set objSecure = server.createobject("inetsolution.secure") set objConn = objSecure.Conn set objRS = Server.CreateObject("ADODB.Recordset") strSQL = "select GROUPQUOTEEMAIL, SITETITLE,SITEDOMAIN,CONTACTEMAIL from SITEPARAMS" objRS.Open strSQL, objConn, adOpenDynamic, adLockOptimistic, adCmdText strSiteTitle = trim(objRS("SITETITLE")) strSiteDomain = trim(objRS("SITEDOMAIN")) strCmd = trim(request.form("cmd")) select case strCmd case "send" strCompanyName = trim(request.form("companyName")) strAddress = trim(request.form("address")) strCity = trim(request.form("city")) strState = trim(request.form("state")) strZip = trim(request.form("zip")) strGroupContact = trim(request.form("groupContact")) strGroupPhone = trim(request.form("groupPhone")) strGroupEmail = trim(request.form("groupEmail")) strNatureBusiness = trim(request.form("natureBusiness")) strCurrentCarrier = trim(request.form("currentCarrier")) strHourlyMinimum = trim(request.form("hourlyMinimum")) strName1 = trim(request.form("name1")) strGender1 = trim(request.form("gender1")) strDOB1 = trim(request.form("dob1")) strDependentStatus1 = trim(request.form("dependentStatus1")) strWaivingMedical1 = trim(request.form("waivingMedical1")) strHoursPerWeek1 = trim(request.form("hoursPerWeek1")) strName2 = trim(request.form("name2")) strGender2= trim(request.form("gender2")) strDOB2= trim(request.form("dob2")) strDependentStatus2 = trim(request.form("dependentStatus2")) strWaivingMedical2 = trim(request.form("waivingMedical2")) strHoursPerWeek2 = trim(request.form("hoursPerWeek2")) strName3 = trim(request.form("name3")) strGender3= trim(request.form("gender3")) strDOB3= trim(request.form("dob3")) strDependentStatus3 = trim(request.form("dependentStatus3")) strWaivingMedical3 = trim(request.form("waivingMedical3")) strHoursPerWeek3 = trim(request.form("hoursPerWeek3")) strName4 = trim(request.form("name4")) strGender4= trim(request.form("gender4")) strDOB4= trim(request.form("dob4")) strDependentStatus4 = trim(request.form("dependentStatus4")) strWaivingMedical4 = trim(request.form("waivingMedical4")) strHoursPerWeek4 = trim(request.form("hoursPerWeek4")) strName5 = trim(request.form("name5")) strGender5= trim(request.form("gender5")) strDOB5= trim(request.form("dob5")) strDependentStatus5 = trim(request.form("dependentStatus5")) strWaivingMedical5 = trim(request.form("waivingMedical5")) strHoursPerWeek5 = trim(request.form("hoursPerWeek5")) strName6 = trim(request.form("name6")) strGender6= trim(request.form("gender6")) strDOB6= trim(request.form("dob6")) strDependentStatus6 = trim(request.form("dependentStatus6")) strWaivingMedical6 = trim(request.form("waivingMedical6")) strHoursPerWeek6 = trim(request.form("hoursPerWeek6")) strName7 = trim(request.form("name7")) strGender7= trim(request.form("gender7")) strDOB7= trim(request.form("dob7")) strDependentStatus7 = trim(request.form("dependentStatus7")) strWaivingMedical7 = trim(request.form("waivingMedical7")) strHoursPerWeek7 = trim(request.form("hoursPerWeek7")) strName8 = trim(request.form("name8")) strGender8= trim(request.form("gender8")) strDOB8= trim(request.form("dob8")) strDependentStatus8 = trim(request.form("dependentStatus8")) strWaivingMedical8 = trim(request.form("waivingMedical8")) strHoursPerWeek8 = trim(request.form("hoursPerWeek8")) strName9 = trim(request.form("name9")) strGender9= trim(request.form("gender9")) strDOB9= trim(request.form("dob9")) strDependentStatus9 = trim(request.form("dependentStatus9")) strWaivingMedical9 = trim(request.form("waivingMedical9")) strHoursPerWeek9 = trim(request.form("hoursPerWeek9")) strName10 = trim(request.form("name10")) strGender10= trim(request.form("gender10")) strDOB10= trim(request.form("dob10")) strDependentStatus10 = trim(request.form("dependentStatus10")) strWaivingMedical10 = trim(request.form("waivingMedical10")) strHoursPerWeek10 = trim(request.form("hoursPerWeek10")) strName11 = trim(request.form("name11")) strGender11= trim(request.form("gender11")) strDOB11= trim(request.form("dob11")) strDependentStatus11 = trim(request.form("dependentStatus11")) strWaivingMedical11 = trim(request.form("waivingMedical11")) strHoursPerWeek11 = trim(request.form("hoursPerWeek11")) strName12 = trim(request.form("name12")) strGender12= trim(request.form("gender12")) strDOB12= trim(request.form("dob12")) strDependentStatus12 = trim(request.form("dependentStatus12")) strWaivingMedical12 = trim(request.form("waivingMedical12")) strHoursPerWeek12 = trim(request.form("hoursPerWeek12")) strName13 = trim(request.form("name13")) strGender13= trim(request.form("gender13")) strDOB13= trim(request.form("dob13")) strDependentStatus13 = trim(request.form("dependentStatus13")) strWaivingMedical13 = trim(request.form("waivingMedical13")) strHoursPerWeek13 = trim(request.form("hoursPerWeek13")) strName14 = trim(request.form("name14")) strGender14= trim(request.form("gender14")) strDOB14= trim(request.form("dob14")) strDependentStatus14 = trim(request.form("dependentStatus14")) strWaivingMedical14 = trim(request.form("waivingMedical14")) strHoursPerWeek14 = trim(request.form("hoursPerWeek14")) strName15 = trim(request.form("name15")) strGender15= trim(request.form("gender15")) strDOB15= trim(request.form("dob15")) strDependentStatus15 = trim(request.form("dependentStatus15")) strWaivingMedical15 = trim(request.form("waivingMedical15")) strHoursPerWeek15 = trim(request.form("hoursPerWeek15")) strName16 = trim(request.form("name16")) strGender16= trim(request.form("gender16")) strDOB16= trim(request.form("dob16")) strDependentStatus16 = trim(request.form("dependentStatus16")) strWaivingMedical16 = trim(request.form("waivingMedical16")) strHoursPerWeek16 = trim(request.form("hoursPerWeek16")) strName17 = trim(request.form("name17")) strGender17= trim(request.form("gender17")) strDOB17= trim(request.form("dob17")) strDependentStatus17 = trim(request.form("dependentStatus17")) strWaivingMedical17 = trim(request.form("waivingMedical17")) strHoursPerWeek17 = trim(request.form("hoursPerWeek17")) strName18 = trim(request.form("name18")) strGender18= trim(request.form("gender18")) strDOB18= trim(request.form("dob18")) strDependentStatus18 = trim(request.form("dependentStatus18")) strWaivingMedical18 = trim(request.form("waivingMedical18")) strHoursPerWeek18 = trim(request.form("hoursPerWeek18")) strName19 = trim(request.form("name19")) strGender19= trim(request.form("gender19")) strDOB19= trim(request.form("dob19")) strDependentStatus19 = trim(request.form("dependentStatus19")) strWaivingMedical19 = trim(request.form("waivingMedical19")) strHoursPerWeek19 = trim(request.form("hoursPerWeek19")) strName20 = trim(request.form("name20")) strGender20= trim(request.form("gender20")) strDOB20= trim(request.form("dob20")) strDependentStatus20 = trim(request.form("dependentStatus20")) strWaivingMedical20 = trim(request.form("waivingMedical20")) strHoursPerWeek20 = trim(request.form("hoursPerWeek20")) strBody = "Date Posted: " & now() & vbCrLf & vbCrLf strBody = strBody & "Contact Information" & vbCrLf & "----------------------" & vbCrLf if strCompanyName <> "" then strBody = strBody & "Company Name: " & strCompanyName & vbCrLf end if if strAddress <> "" then strBody = strBody & "Address: " & strAddress & vbCrLf end if if strCity <> "" then strBody = strBody & "City: " & strCity & vbCrLf end if if strState <> "" then strBody = strBody & "State: " & strState & vbCrLf end if if strZip <> "" then strBody = strBody & "Zip: " & strZip & vbCrLf end if if strGroupContact <> "" then strBody = strBody & "Group Contact Name: " & strGroupContact & vbCrLf end if if strGroupPhone <> "" then strBody = strBody & "Group Contact Phone: " & strGroupPhone & vbCrLf end if if strGroupEmail <> "" then strBody = strBody & "Group Contact Email: " & strGroupEmail & vbCrLf end if if strNatureBusiness <> "" then strBody = strBody & "Nature of Business/SIC Code: " & strNatureBusiness & vbCrLf end if if strCurrentCarrier <> "" then strBody = strBody & "Current Carrier: " & strCurrentCarrier & vbCrLf end if if strHourlyMinimum <> "" then strBody = strBody & "Minimum Hours for Insurance: " & strHourlyMinimum & vbCrLf & vbCrLf end if strBody = strBody & "Census Information" & vbCrLf & "----------------------" & vbCrLf if strName1 <> "" then strBody = strBody & "Full Name: " & strName1 & vbCrLf strBody = strBody & "Gender: " & strGender1 & vbCrLf strBody = strBody & "Date of Birth: " & strDOB1 & vbCrLf strBody = strBody & "Dependent Status: " & strDependentStatus1 & vbCrLf strBody = strBody & "Waiving medical: " & strWaivingMedical1 & vbCrLf strBody = strBody & "Hours Per Week: " & strHoursPerWeek1 & vbCrLf & vbCrLf end if if strName2 <> "" then strBody = strBody & "Full Name: " & strName2 & vbCrLf strBody = strBody & "Gender: " & strGender2 & vbCrLf strBody = strBody & "Date of Birth: " & strDOB2 & vbCrLf strBody = strBody & "Dependent Status: " & strDependentStatus2 & vbCrLf strBody = strBody & "Waiving medical: " & strWaivingMedical2 & vbCrLf strBody = strBody & "Hours Per Week: " & strHoursPerWeek2 & vbCrLf & vbCrLf end if if strName3 <> "" then strBody = strBody & "Full Name: " & strName3 & vbCrLf strBody = strBody & "Gender: " & strGender3 & vbCrLf strBody = strBody & "Date of Birth: " & strDOB3 & vbCrLf strBody = strBody & "Dependent Status: " & strDependentStatus3 & vbCrLf strBody = strBody & "Waiving medical: " & strWaivingMedical3 & vbCrLf strBody = strBody & "Hours Per Week: " & strHoursPerWeek3 & vbCrLf & vbCrLf end if if strName4 <> "" then strBody = strBody & "Full Name: " & strName4 & vbCrLf strBody = strBody & "Gender: " & strGender4 & vbCrLf strBody = strBody & "Date of Birth: " & strDOB4 & vbCrLf strBody = strBody & "Dependent Status: " & strDependentStatus4 & vbCrLf strBody = strBody & "Waiving medical: " & strWaivingMedical4 & vbCrLf strBody = strBody & "Hours Per Week: " & strHoursPerWeek4 & vbCrLf & vbCrLf end if if strName5 <> "" then strBody = strBody & "Full Name: " & strName5 & vbCrLf strBody = strBody & "Gender: " & strGender5 & vbCrLf strBody = strBody & "Date of Birth: " & strDOB5 & vbCrLf strBody = strBody & "Dependent Status: " & strDependentStatus5 & vbCrLf strBody = strBody & "Waiving medical: " & strWaivingMedical5 & vbCrLf strBody = strBody & "Hours Per Week: " & strHoursPerWeek5 & vbCrLf & vbCrLf end if if strName6 <> "" then strBody = strBody & "Full Name: " & strName6 & vbCrLf strBody = strBody & "Gender: " & strGender6 & vbCrLf strBody = strBody & "Date of Birth: " & strDOB6 & vbCrLf strBody = strBody & "Dependent Status: " & strDependentStatus6 & vbCrLf strBody = strBody & "Waiving medical: " & strWaivingMedical6 & vbCrLf strBody = strBody & "Hours Per Week: " & strHoursPerWeek6 & vbCrLf & vbCrLf end if if strName7 <> "" then strBody = strBody & "Full Name: " & strName7 & vbCrLf strBody = strBody & "Gender: " & strGender7 & vbCrLf strBody = strBody & "Date of Birth: " & strDOB7 & vbCrLf strBody = strBody & "Dependent Status: " & strDependentStatus7 & vbCrLf strBody = strBody & "Waiving medical: " & strWaivingMedical7 & vbCrLf strBody = strBody & "Hours Per Week: " & strHoursPerWeek7 & vbCrLf & vbCrLf end if if strName8 <> "" then strBody = strBody & "Full Name: " & strName8 & vbCrLf strBody = strBody & "Gender: " & strGender8 & vbCrLf strBody = strBody & "Date of Birth: " & strDOB8 & vbCrLf strBody = strBody & "Dependent Status: " & strDependentStatus8 & vbCrLf strBody = strBody & "Waiving medical: " & strWaivingMedical8 & vbCrLf strBody = strBody & "Hours Per Week: " & strHoursPerWeek8 & vbCrLf & vbCrLf end if if strName9 <> "" then strBody = strBody & "Full Name: " & strName9 & vbCrLf strBody = strBody & "Gender: " & strGender9 & vbCrLf strBody = strBody & "Date of Birth: " & strDOB9 & vbCrLf strBody = strBody & "Dependent Status: " & strDependentStatus9 & vbCrLf strBody = strBody & "Waiving medical: " & strWaivingMedical9 & vbCrLf strBody = strBody & "Hours Per Week: " & strHoursPerWeek9 & vbCrLf & vbCrLf end if if strName10 <> "" then strBody = strBody & "Full Name: " & strName10 & vbCrLf strBody = strBody & "Gender: " & strGender10 & vbCrLf strBody = strBody & "Date of Birth: " & strDOB10 & vbCrLf strBody = strBody & "Dependent Status: " & strDependentStatus10 & vbCrLf strBody = strBody & "Waiving medical: " & strWaivingMedical10 & vbCrLf strBody = strBody & "Hours Per Week: " & strHoursPerWeek10 & vbCrLf & vbCrLf end if if strName11 <> "" then strBody = strBody & "Full Name: " & strName11 & vbCrLf strBody = strBody & "Gender: " & strGender11 & vbCrLf strBody = strBody & "Date of Birth: " & strDOB11 & vbCrLf strBody = strBody & "Dependent Status: " & strDependentStatus11 & vbCrLf strBody = strBody & "Waiving medical: " & strWaivingMedical11 & vbCrLf strBody = strBody & "Hours Per Week: " & strHoursPerWeek11 & vbCrLf & vbCrLf end if if strName12 <> "" then strBody = strBody & "Full Name: " & strName12 & vbCrLf strBody = strBody & "Gender: " & strGender12 & vbCrLf strBody = strBody & "Date of Birth: " & strDOB12 & vbCrLf strBody = strBody & "Dependent Status: " & strDependentStatus12 & vbCrLf strBody = strBody & "Waiving medical: " & strWaivingMedical12 & vbCrLf strBody = strBody & "Hours Per Week: " & strHoursPerWeek12 & vbCrLf & vbCrLf end if if strName13 <> "" then strBody = strBody & "Full Name: " & strName13 & vbCrLf strBody = strBody & "Gender: " & strGender13 & vbCrLf strBody = strBody & "Date of Birth: " & strDOB13 & vbCrLf strBody = strBody & "Dependent Status: " & strDependentStatus13 & vbCrLf strBody = strBody & "Waiving medical: " & strWaivingMedical13 & vbCrLf strBody = strBody & "Hours Per Week: " & strHoursPerWeek13 & vbCrLf & vbCrLf end if if strName14 <> "" then strBody = strBody & "Full Name: " & strName14 & vbCrLf strBody = strBody & "Gender: " & strGender14 & vbCrLf strBody = strBody & "Date of Birth: " & strDOB14 & vbCrLf strBody = strBody & "Dependent Status: " & strDependentStatus14 & vbCrLf strBody = strBody & "Waiving medical: " & strWaivingMedical14 & vbCrLf strBody = strBody & "Hours Per Week: " & strHoursPerWeek14 & vbCrLf & vbCrLf end if if strName15 <> "" then strBody = strBody & "Full Name: " & strName15 & vbCrLf strBody = strBody & "Gender: " & strGender15 & vbCrLf strBody = strBody & "Date of Birth: " & strDOB15 & vbCrLf strBody = strBody & "Dependent Status: " & strDependentStatus15 & vbCrLf strBody = strBody & "Waiving medical: " & strWaivingMedical15 & vbCrLf strBody = strBody & "Hours Per Week: " & strHoursPerWeek15 & vbCrLf & vbCrLf end if if strName16 <> "" then strBody = strBody & "Full Name: " & strName16 & vbCrLf strBody = strBody & "Gender: " & strGender16 & vbCrLf strBody = strBody & "Date of Birth: " & strDOB16 & vbCrLf strBody = strBody & "Dependent Status: " & strDependentStatus16 & vbCrLf strBody = strBody & "Waiving medical: " & strWaivingMedical16 & vbCrLf strBody = strBody & "Hours Per Week: " & strHoursPerWeek16 & vbCrLf & vbCrLf end if if strName17 <> "" then strBody = strBody & "Full Name: " & strName17 & vbCrLf strBody = strBody & "Gender: " & strGender17 & vbCrLf strBody = strBody & "Date of Birth: " & strDOB17 & vbCrLf strBody = strBody & "Dependent Status: " & strDependentStatus17 & vbCrLf strBody = strBody & "Waiving medical: " & strWaivingMedical17 & vbCrLf strBody = strBody & "Hours Per Week: " & strHoursPerWeek17 & vbCrLf & vbCrLf end if if strName18 <> "" then strBody = strBody & "Full Name: " & strName18 & vbCrLf strBody = strBody & "Gender: " & strGender18 & vbCrLf strBody = strBody & "Date of Birth: " & strDOB18 & vbCrLf strBody = strBody & "Dependent Status: " & strDependentStatus18 & vbCrLf strBody = strBody & "Waiving medical: " & strWaivingMedical18 & vbCrLf strBody = strBody & "Hours Per Week: " & strHoursPerWeek18 & vbCrLf & vbCrLf end if if strName19 <> "" then strBody = strBody & "Full Name: " & strName19 & vbCrLf strBody = strBody & "Gender: " & strGender19 & vbCrLf strBody = strBody & "Date of Birth: " & strDOB19 & vbCrLf strBody = strBody & "Dependent Status: " & strDependentStatus19 & vbCrLf strBody = strBody & "Waiving medical: " & strWaivingMedical19 & vbCrLf strBody = strBody & "Hours Per Week: " & strHoursPerWeek19 & vbCrLf & vbCrLf end if if strName20 <> "" then strBody = strBody & "Full Name: " & strName20 & vbCrLf strBody = strBody & "Gender: " & strGender20 & vbCrLf strBody = strBody & "Date of Birth: " & strDOB20 & vbCrLf strBody = strBody & "Dependent Status: " & strDependentStatus20 & vbCrLf strBody = strBody & "Waiving medical: " & strWaivingMedical20 & vbCrLf strBody = strBody & "Hours Per Week: " & strHoursPerWeek20 & vbCrLf & vbCrLf end if strBody = strBody & vbCrLf & vbCrLf & "-----------------" & vbCrLf & "End Message" Set objMailer = Server.CreateObject("SMTPsvg.Mailer") objMailer.FromName = strSiteTitle & " InetActive" objMailer.FromAddress= "webmaster@" & strSiteDomain objMailer.RemoteHost = "relay.inetsolution.com;smtp.inetsolution.com" on error resume next arrEmailAddress = split(trim(objSecure.Conn.execute("select GROUPQUOTEEMAIL from SITEPARAMS")(0)),",") on error goto 0 if isarray(arrEmailAddress) then for intA = 0 to ubound(arrEmailAddress) objMailer.AddRecipient "John J. Boyd & Associates", arrEmailAddress(intA) next 'intA else objMailer.AddRecipient "John J. Boyd & Associates Contact Form issue(email problem)","webmaster@inetsolution.com" end if objRS.Close set objRS = nothing objConn.Close objMailer.Subject = strSiteTitle & " Contact Form" objMailer.BodyText = strBody if objMailer.sendMail then if strGroupEmail <> "" then 'Send auto responder text to the user strBody = "" objMailer.ClearRecipients objMailer.ClearBodyText strBody = strGroupContact & "," & vbCrLf & vbCrLf strBody = strBody & "Thank you for contacting John J. Boyd & Associates. We will respond to your inquiry " strBody = strBody & "within two business days. If you would like immediate assistance, you may call us at (586) 314-3400. We appreciate the opportunity to serve you." & vbCrLf strBody = strBody & vbCrlF & vbCrLf & "Sincerly," & vbCrLf & "John J. Boyd & Associates" & vbCrLf objMailer.FromName = strSiteTitle objMailer.FromAddress= "webmaster@" & strSiteDomain objMailer.RemoteHost = "relay.inetsolution.com" objMailer.AddRecipient strGroupContact, strGroupEmail objMailer.Subject = strSiteTitle & " John J. Boyd & Associates Contact" objMailer.BodyText = strBody objMailer.SendMail end if response.redirect("submission-success.html") else response.redirect("census-request.html?r=f") end if set objMailer = Nothing case else 'Just let the page load end select %> John J. Boyd & Associates, Inc. - Census Request

Census Request

Company Information

Complete this form to receive a quote for group health insurance for your company or organization.

example: (555) 555-1212 x212
example: yourname@yourhost.com