';
$leftColWidth='50%';
$text_style='';
$redirect='thanks.html';
$fields=array
(
array
(
'label'=>'Full Name',
'short_label'=>'Name',
'type'=>'full_name',
'required'=>true,
'extra'=>'reply_name',
'cookie'=>'full_name',
'value'=>''
),
array
(
'label'=>'Business Name',
'type'=>'text_restricted',
'required'=>false,
'cookie'=>'company_name',
'value'=>''
),
array
(
'label'=>'Address',
'type'=>'address',
'required'=>false,
'cookie'=>'address',
'value'=>''
),
array
(
'label'=>'City',
'type'=>'text_restricted',
'required'=>false,
'cookie'=>'city',
'value'=>''
),
array
(
'label'=>'State',
'type'=>'select',
'required'=>false,
'options'=>'$stateProvince_abbr',
'cookie'=>'state',
'value'=>'MA'
),
array
(
'label'=>'Postal Code',
'type'=>'zip',
'required'=>false,
'cookie'=>'postal_code',
'value'=>''
),
array
(
'label'=>'Phone',
'type'=>'phone',
'required'=>true,
'cookie'=>'phone',
'value'=>''
),
array
(
'label'=>'Fax',
'type'=>'phone',
'required'=>false,
'cookie'=>'fax',
'value'=>''
),
array
(
'label'=>'E-mail Address',
'short_label'=>'E-mail',
'type'=>'email',
'required'=>true,
'extra'=>'reply-to',
'cookie'=>'email',
'value'=>''
),
array
(
'type'=>'note',
'html'=>'
General area(s) of interest:'
),
array
(
'label'=>'Interest',
'type'=>'mailOutput_list',
'items'=>array('Personal Insurance','Commercial Insurance','Health & Life Insurance'),
'delimeter'=>', '
),
array
(
'label'=>'Personal Insurance',
'mailOutput_hide'=>true,
'type'=>'checkbox',
'required'=>false,
'value'=>'Personal Insurance',
'checked'=>false
),
array
(
'label'=>'Commercial Insurance',
'mailOutput_hide'=>true,
'type'=>'checkbox',
'required'=>false,
'value'=>'Commercial Insurance',
'checked'=>false
),
array
(
'label'=>'Health & Life Insurance',
'mailOutput_hide'=>true,
'type'=>'checkbox',
'required'=>false,
'value'=>'Health & Life Insurance',
'checked'=>false
),
array
(
'type'=>'note',
'html'=>'
Preferred method(s) of contact:'
),
array
(
'label'=>'Contact by',
'type'=>'mailOutput_list',
'items'=>array('E-Mail','Telephone','Fax','Mail'),
'delimeter'=>' / '
),
array
(
'label'=>'E-Mail',
'mailOutput_hide'=>true,
'type'=>'checkbox',
'required'=>false,
'value'=>'E-Mail',
'cookie'=>'contactBy_email',
'checked'=>false
),
array
(
'label'=>'Telephone',
'mailOutput_hide'=>true,
'type'=>'checkbox',
'required'=>false,
'dynamic_control'=>true,
'dynamic_identifiers'=>array('checked'=>'best_time'),
'value'=>'Telephone',
'cookie'=>'contactBy_phone',
'checked'=>false
),
array
(
'label'=>'Fax',
'mailOutput_hide'=>true,
'type'=>'checkbox',
'required'=>false,
'value'=>'Fax',
'cookie'=>'contactBy_fax',
'checked'=>false
),
array
(
'label'=>'Mail',
'mailOutput_hide'=>true,
'type'=>'checkbox',
'required'=>false,
'value'=>'Mail',
'cookie'=>'contactBy_mail',
'checked'=>false
),
array
(
'type'=>'note',
'dynamic_field'=>true,
'dynamic_identifier'=>'best_time',
'html'=>'
Best time(s) to contact you by phone:'
),
array
(
'label'=>'Call',
'type'=>'mailOutput_list',
'items'=>array('Morning','Afternoon','Evening'),
'delimeter'=>' / '
),
array
(
'label'=>'Morning',
'mailOutput_hide'=>true,
'type'=>'checkbox',
'required'=>false,
'dynamic_field'=>true,
'dynamic_identifier'=>'best_time',
'value'=>'Morning',
'cookie'=>'bestTime_morning',
'checked'=>false
),
array
(
'label'=>'Afternoon',
'mailOutput_hide'=>true,
'type'=>'checkbox',
'required'=>false,
'dynamic_field'=>true,
'dynamic_identifier'=>'best_time',
'value'=>'Afternoon',
'cookie'=>'bestTime_afternoon',
'checked'=>false
),
array
(
'label'=>'Evening',
'mailOutput_hide'=>true,
'type'=>'checkbox',
'required'=>false,
'dynamic_field'=>true,
'dynamic_identifier'=>'best_time',
'value'=>'Evening',
'cookie'=>'bestTime_evening',
'checked'=>false
),
array
(
'label'=>'How may we be of particular assistance at this time?',
'short_label'=>'Specifics',
'wide'=>true,
'type'=>'textarea',
'required'=>false,
'value'=>''
),
array
(
'type'=>'note',
'html'=>'
Click here to read our privacy policy.
'
)
);
mailer();
?>
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