More Information

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Please complete the form below to receive a quote for home owners insurance.

Please note: All information entered will be considered confidential. Please read our privacy policy.

Name :
Property Address:
City:
State:	Zip:

Telephone:
Email Address:


Year Built:
Structure:Brick, Frame :
Approximate value:
Alarm:
Deductible:

Comments:

<% else Set Mailer = Server.CreateObject("SMTPsvg.Mailer") Mailer.FromName = "Information Request" Mailer.FromAddress = "Internet User" strMailHost = "mail.athcon.net" Mailer.RemoteHost = strMailHost Mailer.AddRecipient "Information", "info@paragon-ins.com" strBody = ("Request for Service") & Chr(13) & Chr(10) strBody = strBody & "------------------------------------------" & Chr(13) & Chr(10) strBody = strBody & ("Contact Name: ") & request("Contactname")& Chr(13) & Chr(10) strBody = strBody & ("Address: ") & request("address")& Chr(13) & Chr(10) strBody = strBody & ("Telephone: ") & request("Telephone")& Chr(13) & Chr(10) strBody = strBody & ("Email Address: ") & request("emailaddress")& Chr(13) & Chr(10) strBody = strBody & ("City: ") & request("city")& Chr(13) & Chr(10) strBody = strBody & ("State: ") & request("state")& Chr(13) & Chr(10) strBody = strBody & ("Zip: ") & request("zip")& Chr(13) & Chr(10) strBody = strBody & ("Date: ") & request("date")& Chr(13) & Chr(10) strBody = strBody & ("Tobacco_36:") & request("T36")& Chr(13) & Chr(10) strBody = strBody & ("Tobacco_60:") & request("T60")& Chr(13) & Chr(10) strBody = strBody & ("treatment:") & request("Treatment")& Chr(13) & Chr(10) strBody = strBody & ("Comments:") & request("comments")& Chr(13) & Chr(10) if rtrim(request("Telephones")) = "ON" then strBody = strBody & ("Type of Problem: Telephones") & request("telephones ")& Chr(13) & Chr(10) end if if rtrim(request("Voicemail")) = "ON" then strBody = strBody & ("Type of Problem: Voicemail") & request("voicemail ")& Chr(13) & Chr(10) end if if rtrim(request("Computers")) = "ON" then strBody = strBody & ("Type of Problem: Computers") & request("computers ")& Chr(13) & Chr(10) strBody = strBody & "------------------------------------------" & Chr(13) & Chr(10) else strBody = strBody & "------------------------------------------" & Chr(13) & Chr(10) end if Mailer.BodyText = strBody if Mailer.SendMail then Response.Write "" else Response.Write "Mailing Failed.

" Response.Write Mailer.Response end if %>

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