More Information

<% if request("action") = "" then %>

Please complete the form below to receive a quote for Life Insurance.

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

Name :
Address:
City:
State:	Zip:

Telephone:
Email Address:


	Has the candidate used tobacco in the past 36 months?
	Has the candidate used tobacco in the past 60 months?
	Has the candidate ever been treated or sought treatment for diabetes, heart disease, cancer, or cardiovascular disease?
	Please select the coverage required. $100,000 $250,000
		$250,000 $1M	Other.
	Please select the policy term. 1 Year 10 Year 15 Year 20 Year


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 %>

<% end if %>