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tjromano

auto.html

tjromano
May 14th, 2012
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  1. <?php session_start(); ?>
  2. <?
  3. if (isset($_POST['submit'])) {
  4. include('auto.php');
  5. } else {
  6. $insuredName = '';
  7. $address = '';
  8. $city = '';
  9. $state = '';
  10. $zip = '';
  11. $phone = '';
  12. $email = '';
  13. $dobMonth = '';
  14. $dobDay = '';
  15. $dobYear = '';
  16. $driversLicense = '';
  17. $doYou = '';
  18. $bodilyInjury = '';
  19. $propertyDamage = '';
  20. $medicalPayments = '';
  21. $comprehensiveDeductible = '';
  22. $collisionDeductible = '';
  23. $rentalReimbursement = '';
  24. $towing = '';
  25. $v1year = '';
  26. $v1make = '';
  27. $v1vin = '';
  28. $v2year = '';
  29. $v2make = '';
  30. $v2vin = '';
  31. $otherDrivers = '';
  32. $howMany = '';
  33. $permission = '';
  34. $ssn = '';
  35. $errorFields = array();
  36. }
  37. ?>
  38.  
  39. <!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
  40. <html>
  41. <head>
  42. <meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1">
  43. <meta name="keywords" content="Connecticut auto insurance, auto insurance Connecticut, car insurance Connecticut, auto insurance in Connecticut, Connecticut automobile insurance, Connecticut motorcycle insurance, Connecticut car insurance quotes, Connecticut auto insurance quotes, Connecticut car insurance quote, Connecticut auto insurance quote, Connecticut auto insurance requirements, Connecticut auto insurance rates, Connecticut car insurance rates, Connecticut car insurance requirements"/>
  44. <meta name="description" content="Find the best Connecticut auto insurance rates through Tracy-Driscoll Insurance & Financial Services in Bristol CT. Get best quote for truck, motorcycle or car insurance in CT."/>
  45. <title>Connecticut Auto Insurance</title>
  46.  
  47. <script type="text/JavaScript">
  48. <!--
  49. function MM_preloadImages() { //v3.0
  50. var d=document; if(d.images){ if(!d.MM_p) d.MM_p=new Array();
  51. var i,j=d.MM_p.length,a=MM_preloadImages.arguments; for(i=0; i<a.length; i++)
  52. if (a[i].indexOf("#")!=0){ d.MM_p[j]=new Image; d.MM_p[j++].src=a[i];}}
  53. }
  54. function MM_swapImgRestore() { //v3.0
  55. var i,x,a=document.MM_sr; for(i=0;a&&i<a.length&&(x=a[i])&&x.oSrc;i++) x.src=x.oSrc;
  56. }
  57. function MM_findObj(n, d) { //v4.01
  58. var p,i,x; if(!d) d=document; if((p=n.indexOf("?"))>0&&parent.frames.length) {
  59. d=parent.frames[n.substring(p+1)].document; n=n.substring(0,p);}
  60. if(!(x=d[n])&&d.all) x=d.all[n]; for (i=0;!x&&i<d.forms.length;i++) x=d.forms[i][n];
  61. for(i=0;!x&&d.layers&&i<d.layers.length;i++) x=MM_findObj(n,d.layers[i].document);
  62. if(!x && d.getElementById) x=d.getElementById(n); return x;
  63. }
  64.  
  65. function MM_swapImage() { //v3.0
  66. var i,j=0,x,a=MM_swapImage.arguments; document.MM_sr=new Array; for(i=0;i<(a.length-2);i+=3)
  67. if ((x=MM_findObj(a[i]))!=null){document.MM_sr[j++]=x; if(!x.oSrc) x.oSrc=x.src; x.src=a[i+2];}
  68. }
  69. //-->
  70. </script>
  71. <link href="../lp-style.css" rel="stylesheet" type="text/css" />
  72.  
  73. <link href="g_form.css" rel="stylesheet" type="text/css" />
  74. <link href="baby_blue.css" rel="stylesheet" type="text/css" />
  75.  
  76. <style type="text/css">
  77. <!--
  78. a:link {
  79. color: #000;
  80. }
  81. -->
  82. </style>
  83. <style type="text/css">
  84. .form-label{
  85. width:150px !important;
  86. }
  87. .form-label-left{
  88. width:150px !important;
  89. }
  90. .form-line{
  91. padding:3px;
  92. }
  93. .form-label-right{
  94. width:150px !important;
  95. }
  96. body, html{
  97. margin:0;
  98. padding:0;
  99. background:#ffffff;
  100. }
  101.  
  102. </style>
  103. </head><body onload="MM_preloadImages('../../images/getaquotebutton.png','../../images/businessinsurance_roll.png','../../images/homeinsurance_roll.png','../../images/lifehealthinsurance_roll.png','getautoquote_roll.png')">
  104. <div id="container-blank-cycle">
  105. <div class="header"></div>
  106. <div id="topnavContainer">
  107. </div>
  108. <div id="automotive_bkgrd">
  109. <div id="automotive_textboxB">
  110. <p><span class="automotive_text"><strong>GET YOUR AUTO QUOTE IN <u>2 EASY STEPS</u> AND IN LESS THAN 5 MINUTES!</strong></span><br /><br />
  111.  
  112. <span class="headline_text-orange">STEP 1</span></p>
  113. <p><form class="auto_quote" action="auto.php" method="post" name="auto" id="auto_quote" accept-charset="utf-8"><input type="hidden" name="Submit" value="Submit" />
  114. <div class="form-all">
  115. <ul class="form-section">
  116. <li id="header1" class="form-input-wide">
  117. <div class="form-header-group">
  118. <h3 id="header2" class="form-header">
  119. Insured Information
  120. </h3>
  121. </div>
  122. </li>
  123. <li class="form-line" id="cid_1">
  124. <label class="form-label-left" id="insuredName_label" for="insuredName">
  125. Insured Name<span class="form-required">*</span>
  126. </label>
  127. <div id="insuredName" class="form-input">
  128. <input type="text" class="form-textbox validate[required]" id="insuredName" name="insuredName" size="40" />
  129. </div>
  130. </li>
  131. <li class="form-line" id="cid_2">
  132. <label class="form-label-left" id="address_label" for="address"> Address </label>
  133. <div id="cid_2" class="form-input">
  134. <input type="text" class="form-textbox" id="address" name="address" size="40" />
  135. </div>
  136. </li>
  137. <li class="form-line" id="id_3">
  138. <label class="form-label-left" id="city_label" for="city"> City </label>
  139. <div id="cid_3" class="form-input">
  140. <input type="text" class="form-textbox" id="city" name="city" size="25" />
  141. </div>
  142. </li>
  143. <li class="form-line" id="id_4">
  144. <label class="form-label-left" id="state_label" for="state"> State/Province </label>
  145. <div id="state" class="form-input">
  146. <input type="text" class="form-textbox" id="state" name="state" size="2" />
  147. </div>
  148. </li>
  149. <li class="form-line" id="id_5">
  150. <label class="form-label-left" id="zip_label" for="zip"> Zip/Postal Code </label>
  151. <div id="zip" class="form-input">
  152. <input type="text" class="form-textbox" id="zip" name="zip" size="10" />
  153. </div>
  154. </li>
  155. <li class="form-line" id="id_6">
  156. <label class="form-label-left" id="phone_label" for="phone">
  157. Phone<span class="form-required">*</span>
  158. </label>
  159. <div id="phone" class="form-input">
  160. <input type="text" class="form-textbox validate[required]" id="phone" name="phone" size="14" />
  161. </div>
  162. </li>
  163. <li class="form-line" id="id_9">
  164. <label class="form-label-left" id="email_label" for="label">
  165. Email<span class="form-required">*</span>
  166. </label>
  167. <div id="email" class="form-input">
  168. <input type="text" class="form-textbox validate[required, Email]" id="email" name="email" size="40" />
  169. </div>
  170. </li>
  171. <li class="form-line" id="id_10">
  172. <label class="form-label-left" id="dobMonth_label" for="dobMonth"> Date of Birth </label>
  173.  
  174. <div id="dobMonth" class="form-input"><span class="form-sub-label-container"><select class="form-dropdown" name="dobMonth" id="dobMonth">
  175. <option> </option>
  176. <option value="January"<?= $dobMonth == 'January' ? 'selected="selected"' : '' ?>> January </option>
  177. <option value="February"<?= $dobMonth == 'February' ? 'selected="selected"' : '' ?>> February </option>
  178. <option value="March"<?= $dobMonth == 'March' ? 'selected="selected"' : '' ?>> March </option>
  179. <option value="April"<?= $dobMonth == 'April' ? 'selected="selected"' : '' ?>> April </option>
  180. <option value="May"<?= $dobMonth == 'May' ? 'selected="selected"' : '' ?>> May </option>
  181. <option value="June"<?= $dobMonth == 'June' ? 'selected="selected"' : '' ?>> June </option>
  182. <option value="July"<?= $dobMonth == 'July' ? 'selected="selected"' : '' ?>> July </option>
  183. <option value="August"<?= $dobMonth == 'August' ? 'selected="selected"' : '' ?>> August </option>
  184. <option value="September"<?= $dobMonth == 'September' ? 'selected="selected"' : '' ?>> September </option>
  185. <option value="October"<?= $dobMonth == 'October' ? 'selected="selected"' : '' ?>> October </option>
  186. <option value="November"<?= $dobMonth == 'November' ? 'selected="selected"' : '' ?>> November </option>
  187. <option value="December"<?= $dobMonth == 'December' ? 'selected="selected"' : '' ?>> December </option>
  188. </select>
  189. <label class="form-sub-label" for="dobMonth" id="sublabel_month"> Month </label></span><span class="form-sub-label-container">
  190. <select class="form-dropdown" name="dobDay" id="dobDay">
  191. <option> </option>
  192. <option value="1"<?= $dobDay == '01' ? 'selected="selected"' : '' ?>> 1 </option>
  193. <option value="2"<?= $dobDay == '02' ? 'selected="selected"' : '' ?>> 2 </option>
  194. <option value="3"<?= $dobDay == '03' ? 'selected="selected"' : '' ?>> 3 </option>
  195. <option value="4"<?= $dobDay == '04' ? 'selected="selected"' : '' ?>> 4 </option>
  196. <option value="5"<?= $dobDay == '05' ? 'selected="selected"' : '' ?>> 5 </option>
  197. <option value="6"<?= $dobDay == '06' ? 'selected="selected"' : '' ?>> 6 </option>
  198. <option value="7"<?= $dobDay == '07' ? 'selected="selected"' : '' ?>> 7 </option>
  199. <option value="8"<?= $dobDay == '08' ? 'selected="selected"' : '' ?>> 8 </option>
  200. <option value="9"<?= $dobDay == '09' ? 'selected="selected"' : '' ?>> 9 </option>
  201. <option value="10"<?= $dobDay == '10' ? 'selected="selected"' : '' ?>> 10 </option>
  202. <option value="11"<?= $dobDay == '11' ? 'selected="selected"' : '' ?>> 11 </option>
  203. <option value="12"<?= $dobDay == '12' ? 'selected="selected"' : '' ?>> 12 </option>
  204. <option value="13"<?= $dobDay == '13' ? 'selected="selected"' : '' ?>> 13 </option>
  205. <option value="14"<?= $dobDay == '14' ? 'selected="selected"' : '' ?>> 14 </option>
  206. <option value="15"<?= $dobDay == '15' ? 'selected="selected"' : '' ?>> 15 </option>
  207. <option value="16"<?= $dobDay == '16' ? 'selected="selected"' : '' ?>> 16 </option>
  208. <option value="17"<?= $dobDay == '17' ? 'selected="selected"' : '' ?>> 17 </option>
  209. <option value="18"<?= $dobDay == '18' ? 'selected="selected"' : '' ?>> 18 </option>
  210. <option value="19"<?= $dobDay == '19' ? 'selected="selected"' : '' ?>> 19 </option>
  211. <option value="20"<?= $dobDay == '20' ? 'selected="selected"' : '' ?>> 20 </option>
  212. <option value="21"<?= $dobDay == '21' ? 'selected="selected"' : '' ?>> 21 </option>
  213. <option value="22"<?= $dobDay == '22' ? 'selected="selected"' : '' ?>> 22 </option>
  214. <option value="23"<?= $dobDay == '23' ? 'selected="selected"' : '' ?>> 23 </option>
  215. <option value="24"<?= $dobDay == '24' ? 'selected="selected"' : '' ?>> 24 </option>
  216. <option value="25"<?= $dobDay == '25' ? 'selected="selected"' : '' ?>> 25 </option>
  217. <option value="26"<?= $dobDay == '26' ? 'selected="selected"' : '' ?>> 26 </option>
  218. <option value="27"<?= $dobDay == '27' ? 'selected="selected"' : '' ?>> 27 </option>
  219. <option value="28"<?= $dobDay == '28' ? 'selected="selected"' : '' ?>> 28 </option>
  220. <option value="29"<?= $dobDay == '29' ? 'selected="selected"' : '' ?>> 29 </option>
  221. <option value="30"<?= $dobDay == '30' ? 'selected="selected"' : '' ?>> 30 </option>
  222. <option value="31"<?= $dobDay == '31' ? 'selected="selected"' : '' ?>> 31 </option>
  223. </select>
  224. <label class="form-sub-label" for="dobDay" id="sublabel_day"> Day </label></span><span class="form-sub-label-container"><select class="form-dropdown" name="dobYear" id="dobYear">
  225. <option> </option>
  226. <option value="2016""<?= $dobYear == '2016' ? 'selected="selected"' : '' ?>> 2016 </option>
  227. <option value="2015""<?= $dobYear == '2015' ? 'selected="selected"' : '' ?>> 2015 </option>
  228. <option value="2014""<?= $dobYear == '2014' ? 'selected="selected"' : '' ?>> 2014 </option>
  229. <option value="2013""<?= $dobYear == '2013' ? 'selected="selected"' : '' ?>> 2013 </option>
  230. <option value="2012""<?= $dobYear == '2012' ? 'selected="selected"' : '' ?>> 2012 </option>
  231. <option value="2011""<?= $dobYear == '2011' ? 'selected="selected"' : '' ?>> 2011 </option>
  232. <option value="2010""<?= $dobYear == '2010' ? 'selected="selected"' : '' ?>> 2010 </option>
  233. <option value="2009""<?= $dobYear == '2009' ? 'selected="selected"' : '' ?>> 2009 </option>
  234. <option value="2008""<?= $dobYear == '2008' ? 'selected="selected"' : '' ?>> 2008 </option>
  235. <option value="2007""<?= $dobYear == '2007' ? 'selected="selected"' : '' ?>> 2007 </option>
  236. <option value="2006""<?= $dobYear == '2006' ? 'selected="selected"' : '' ?>> 2006 </option>
  237. <option value="2005""<?= $dobYear == '2005' ? 'selected="selected"' : '' ?>> 2005 </option>
  238. <option value="2004""<?= $dobYear == '2004' ? 'selected="selected"' : '' ?>> 2004 </option>
  239. <option value="2003""<?= $dobYear == '2003' ? 'selected="selected"' : '' ?>> 2003 </option>
  240. <option value="2002""<?= $dobYear == '2002' ? 'selected="selected"' : '' ?>> 2002 </option>
  241. <option value="2001""<?= $dobYear == '2001' ? 'selected="selected"' : '' ?>> 2001 </option>
  242. <option value="2000""<?= $dobYear == '2000' ? 'selected="selected"' : '' ?>> 2000 </option>
  243. <option value="1999""<?= $dobYear == '1999' ? 'selected="selected"' : '' ?>> 1999 </option>
  244. <option value="1998""<?= $dobYear == '1998' ? 'selected="selected"' : '' ?>> 1998 </option>
  245. <option value="1997""<?= $dobYear == '1997' ? 'selected="selected"' : '' ?>> 1997 </option>
  246. <option value="1996""<?= $dobYear == '1996' ? 'selected="selected"' : '' ?>> 1996 </option>
  247. <option value="1995""<?= $dobYear == '1995' ? 'selected="selected"' : '' ?>> 1995 </option>
  248. <option value="1994""<?= $dobYear == '1994' ? 'selected="selected"' : '' ?>> 1994 </option>
  249. <option value="1993""<?= $dobYear == '1993' ? 'selected="selected"' : '' ?>> 1993 </option>
  250. <option value="1992""<?= $dobYear == '1992' ? 'selected="selected"' : '' ?>> 1992 </option>
  251. <option value="1991""<?= $dobYear == '1991' ? 'selected="selected"' : '' ?>> 1991 </option>
  252. <option value="1990""<?= $dobYear == '1990' ? 'selected="selected"' : '' ?>> 1990 </option>
  253. <option value="1989""<?= $dobYear == '1989' ? 'selected="selected"' : '' ?>> 1989 </option>
  254. <option value="1988""<?= $dobYear == '1988' ? 'selected="selected"' : '' ?>> 1988 </option>
  255. <option value="1987""<?= $dobYear == '1987' ? 'selected="selected"' : '' ?>> 1987 </option>
  256. <option value="1986""<?= $dobYear == '1986' ? 'selected="selected"' : '' ?>> 1986 </option>
  257. <option value="1985""<?= $dobYear == '1985' ? 'selected="selected"' : '' ?>> 1985 </option>
  258. <option value="1984""<?= $dobYear == '1984' ? 'selected="selected"' : '' ?>> 1984 </option>
  259. <option value="1983""<?= $dobYear == '1983' ? 'selected="selected"' : '' ?>> 1983 </option>
  260. <option value="1982""<?= $dobYear == '1982' ? 'selected="selected"' : '' ?>> 1982 </option>
  261. <option value="1981""<?= $dobYear == '1981' ? 'selected="selected"' : '' ?>> 1981 </option>
  262. <option value="1980""<?= $dobYear == '1980' ? 'selected="selected"' : '' ?>> 1980 </option>
  263. <option value="1979""<?= $dobYear == '1979' ? 'selected="selected"' : '' ?>> 1979 </option>
  264. <option value="1978""<?= $dobYear == '1978' ? 'selected="selected"' : '' ?>> 1978 </option>
  265. <option value="1977""<?= $dobYear == '1977' ? 'selected="selected"' : '' ?>> 1977 </option>
  266. <option value="1976""<?= $dobYear == '1976' ? 'selected="selected"' : '' ?>> 1976 </option>
  267. <option value="1975""<?= $dobYear == '1975' ? 'selected="selected"' : '' ?>> 1975 </option>
  268. <option value="1974""<?= $dobYear == '1974' ? 'selected="selected"' : '' ?>> 1974 </option>
  269. <option value="1973""<?= $dobYear == '1973' ? 'selected="selected"' : '' ?>> 1973 </option>
  270. <option value="1972""<?= $dobYear == '1972' ? 'selected="selected"' : '' ?>> 1972 </option>
  271. <option value="1971""<?= $dobYear == '1971' ? 'selected="selected"' : '' ?>> 1971 </option>
  272. <option value="1970""<?= $dobYear == '1970' ? 'selected="selected"' : '' ?>> 1970 </option>
  273. <option value="1969""<?= $dobYear == '1969' ? 'selected="selected"' : '' ?>> 1969 </option>
  274. <option value="1968""<?= $dobYear == '1968' ? 'selected="selected"' : '' ?>> 1968 </option>
  275. <option value="1967"<?= $dobYear == '1967' ? 'selected="selected"' : '' ?>> 1967 </option>
  276. <option value="1966"<?= $dobYear == '1966' ? 'selected="selected"' : '' ?>> 1966 </option>
  277. <option value="1965"<?= $dobYear == '1965' ? 'selected="selected"' : '' ?>> 1965 </option>
  278. <option value="1964"<?= $dobYear == '1964' ? 'selected="selected"' : '' ?>> 1964 </option>
  279. <option value="1963"<?= $dobYear == '1963' ? 'selected="selected"' : '' ?>> 1963 </option>
  280. <option value="1962"<?= $dobYear == '1962' ? 'selected="selected"' : '' ?>> 1962 </option>
  281. <option value="1961"<?= $dobYear == '1961' ? 'selected="selected"' : '' ?>> 1961 </option>
  282. <option value="1960"<?= $dobYear == '1960' ? 'selected="selected"' : '' ?>> 1960 </option>
  283. <option value="1959"<?= $dobYear == '1959' ? 'selected="selected"' : '' ?>> 1959 </option>
  284. <option value="1958"<?= $dobYear == '1958' ? 'selected="selected"' : '' ?>> 1958 </option>
  285. <option value="1957"<?= $dobYear == '1957' ? 'selected="selected"' : '' ?>> 1957 </option>
  286. <option value="1956"<?= $dobYear == '1956' ? 'selected="selected"' : '' ?>> 1956 </option>
  287. <option value="1955"<?= $dobYear == '1955' ? 'selected="selected"' : '' ?>> 1955 </option>
  288. <option value="1954"<?= $dobYear == '1954' ? 'selected="selected"' : '' ?>> 1954 </option>
  289. <option value="1953"<?= $dobYear == '1953' ? 'selected="selected"' : '' ?>> 1953 </option>
  290. <option value="1952"<?= $dobYear == '1952' ? 'selected="selected"' : '' ?>> 1952 </option>
  291. <option value="1951"<?= $dobYear == '1951' ? 'selected="selected"' : '' ?>> 1951 </option>
  292. <option value="1950"<?= $dobYear == '1950' ? 'selected="selected"' : '' ?>> 1950 </option>
  293. <option value="1949"<?= $dobYear == '1949' ? 'selected="selected"' : '' ?>> 1949 </option>
  294. <option value="1948"<?= $dobYear == '1948' ? 'selected="selected"' : '' ?>> 1948 </option>
  295. <option value="1947"<?= $dobYear == '1947' ? 'selected="selected"' : '' ?>> 1947 </option>
  296. <option value="1946"<?= $dobYear == '1946' ? 'selected="selected"' : '' ?>> 1946 </option>
  297. <option value="1945"<?= $dobYear == '1945' ? 'selected="selected"' : '' ?>> 1945 </option>
  298. <option value="1944"<?= $dobYear == '1944' ? 'selected="selected"' : '' ?>> 1944 </option>
  299. <option value="1943"<?= $dobYear == '1943' ? 'selected="selected"' : '' ?>> 1943 </option>
  300. <option value="1942"<?= $dobYear == '1942' ? 'selected="selected"' : '' ?>> 1942 </option>
  301. <option value="1941"<?= $dobYear == '1941' ? 'selected="selected"' : '' ?>> 1941 </option>
  302. <option value="1940"<?= $dobYear == '1940' ? 'selected="selected"' : '' ?>> 1940 </option>
  303. <option value="1939"<?= $dobYear == '1939' ? 'selected="selected"' : '' ?>> 1939 </option>
  304. <option value="1938"<?= $dobYear == '1938' ? 'selected="selected"' : '' ?>> 1938 </option>
  305. <option value="1937"<?= $dobYear == '1937' ? 'selected="selected"' : '' ?>> 1937 </option>
  306. <option value="1936"<?= $dobYear == '1936' ? 'selected="selected"' : '' ?>> 1936 </option>
  307. <option value="1935"<?= $dobYear == '1935' ? 'selected="selected"' : '' ?>> 1935 </option>
  308. <option value="1934"<?= $dobYear == '1934' ? 'selected="selected"' : '' ?>> 1934 </option>
  309. <option value="1933"<?= $dobYear == '1933' ? 'selected="selected"' : '' ?>> 1933 </option>
  310. <option value="1932"<?= $dobYear == '1932' ? 'selected="selected"' : '' ?>> 1932 </option>
  311. <option value="1931"<?= $dobYear == '1931' ? 'selected="selected"' : '' ?>> 1931 </option>
  312. <option value="1930"<?= $dobYear == '1930' ? 'selected="selected"' : '' ?>> 1930 </option>
  313. <option value="1929"<?= $dobYear == '1929' ? 'selected="selected"' : '' ?>> 1929 </option>
  314. <option value="1928"<?= $dobYear == '1928' ? 'selected="selected"' : '' ?>> 1928 </option>
  315. <option value="1927"<?= $dobYear == '1927' ? 'selected="selected"' : '' ?>> 1927 </option>
  316. <option value="1926"<?= $dobYear == '1926' ? 'selected="selected"' : '' ?>> 1926 </option>
  317. <option value="1925"<?= $dobYear == '1925' ? 'selected="selected"' : '' ?>> 1925 </option>
  318. <option value="1924"<?= $dobYear == '1924' ? 'selected="selected"' : '' ?>> 1924 </option>
  319. <option value="1923"<?= $dobYear == '1923' ? 'selected="selected"' : '' ?>> 1923 </option>
  320. <option value="1922"<?= $dobYear == '1922' ? 'selected="selected"' : '' ?>> 1922 </option>
  321. <option value="1921"<?= $dobYear == '1921' ? 'selected="selected"' : '' ?>> 1921 </option>
  322. <option value="1920"<?= $dobYear == '1920' ? 'selected="selected"' : '' ?>> 1920 </option>
  323. </select>
  324. <label class="form-sub-label" for="dobYear" id="sublabel_year"> Year </label></span>
  325. </div>
  326. </li>
  327. <li class="form-line" id="id_158">
  328. <label class="form-label-left" id="driversLicense" for="driversLicense_label"> Driver's License # </label>
  329. <div id="driversLicense" class="form-input">
  330. <input type="text" class="form-textbox" id="driversLicense" name="driversLicense" size="25" />
  331. </div>
  332. </li>
  333. <li id="cid_114" class="form-input-wide">
  334. <div class="form-header-group">
  335. <h3 id="header_114" class="form-header">
  336. Current Insurance
  337. </h3>
  338. </div>
  339. </li>
  340. <li class="form-line" id="id_12">
  341. <label class="form-label-left" id="doYou" for="input_10"> Do you presently have Auto Insurance? </label>
  342. <div id="cid_10" class="form-input">
  343. <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio" id="doYou" name="doYou" value="Yes" />
  344. <label for="doYou"> Yes </label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="doYou" name="doYou" value="No" />
  345. <label for="input_10_1"> No </label></span><span class="clearfix"></span>
  346. </div>
  347. </div>
  348. </li>
  349. <li id="cid_115" class="form-input-wide">
  350. <div class="form-header-group">
  351. <h3 id="header_115" class="form-header">
  352. Coverages
  353. </h3>
  354. </div>
  355. </li>
  356. <li class="form-line" id="id_17">
  357. <label class="form-label-left" id="bodilyInjury" for="bodilyInjury"> Bodily Injury Liability </label>
  358. <div id="cid_17" class="form-input">
  359. <select class="form-dropdown" style="width:150px" id="bodilyInjury" name="bodilyInjury">
  360. <option> </option>
  361. <option selected="selected" value=""> </option>
  362. <option value="50/100"<?= $bodilyInjury == '50/100' ? 'selected="selected"' : '' ?>> 50/100 </option>
  363. <option value="100/300"<?= $bodilyInjury == '100/300' ? 'selected="selected"' : '' ?>> 100/300 </option>
  364. <option value="250/500"<?= $bodilyInjury == '250/500' ? 'selected="selected"' : '' ?>> 250/500 </option>
  365. </select>
  366. </div>
  367. </li>
  368. <li class="form-line" id="id_18">
  369. <label class="form-label-left" id="label_18" for="propertyDamage"> Property Damage Liability </label>
  370. <div id="propertyDamage" class="form-input">
  371. <select class="form-dropdown" style="width:150px" id="propertyDamage" name="propertyDamage">
  372. <option> </option>
  373. <option selected="selected" value=""> </option>
  374. <option value="25,000"<?= $propertyDamage == '25,000' ? 'selected="selected"' : '' ?>> 25,000 </option>
  375. <option value="50,000"<?= $propertyDamage == '50,000' ? 'selected="selected"' : '' ?>> 50,000 </option>
  376. <option value="100,000"<?= $propertyDamage == '100,000' ? 'selected="selected"' : '' ?>> 100,000 </option>
  377. </select>
  378. </div>
  379. </li>
  380. <li class="form-line" id="id_19">
  381. <label class="form-label-left" id="medicalPayments_label" for="medicalPayments"> Medical Payments </label>
  382. <div id="cid_19" class="form-input">
  383. <select class="form-dropdown" style="width:150px" id="medicalPayments" name="medicalPayments">
  384. <option> </option>
  385. <option selected="selected" value=""> </option>
  386. <option value="1,000"<?= $medicalPayments == '1,000' ? 'selected="selected"' : '' ?>> 1,000 </option>
  387. <option value="2,500"<?= $medicalPayments == '2,500' ? 'selected="selected"' : '' ?>> 2,500 </option>
  388. <option value="5,000"<?= $medicalPayments == '5,000' ? 'selected="selected"' : '' ?>> 5,000 </option>
  389. </select>
  390. </div>
  391. </li>
  392. <li class="form-line" id="id_24">
  393. <label class="form-label-left" id="comprehensiveDeductible_label" for="comprehensiveDeductible"> Comprehensive Deductible </label>
  394. <div id="cid_24" class="form-input">
  395. <select class="form-dropdown" style="width:150px" id="comprehensiveDeductible" name="comprehensiveDeductible">
  396. <option> </option>
  397. <option selected="selected" value=""> </option>
  398. <option value="No Coverage"<?= $comprehensiveDeductible == 'No Coverage' ? 'selected="selected"' : '' ?>> No Coverage </option>
  399. <option value="250"<?= $comprehensiveDeductible == '250' ? 'selected="selected"' : '' ?>> 250 </option>
  400. <option value="500"<?= $comprehensiveDeductible == '500' ? 'selected="selected"' : '' ?>> 500 </option>
  401. <option value="1,000"<?= $comprehensiveDeductible == '1,000' ? 'selected="selected"' : '' ?>> 1,000 </option>
  402. </select>
  403. </div>
  404. </li>
  405. <li class="form-line" id="id_25">
  406. <label class="form-label-left" id="collisionDeductible_label" for="collisionDeductible"> Collision Deductible </label>
  407. <div id="cid_25" class="form-input">
  408. <select class="form-dropdown" style="width:150px" id="collisionDeductible" name="collisionDeductible">
  409. <option> </option>
  410. <option selected="selected" value=""> </option>
  411. <option value="No Coverage"<?= $collisionDeductible == 'No Coverage' ? 'selected="selected"' : '' ?>> No Coverage </option>
  412. <option value="250"<?= $collisionDeductible == '250' ? 'selected="selected"' : '' ?>> 250 </option>
  413. <option value="500"<?= $collisionDeductible == '500' ? 'selected="selected"' : '' ?>> 500 </option>
  414. <option value="1,000"<?= $collisionDeductible == '1,000' ? 'selected="selected"' : '' ?>> 1,000 </option>
  415. </select>
  416. </div>
  417. </li>
  418. <li class="form-line" id="id_26">
  419. <label class="form-label-left" id="rentalReimbursement_label" for="rentalReimbursement"> Rental Reimbursement </label>
  420. <div id="cid_26" class="form-input">
  421. <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio" id="rentalReimbursement" name="rentalReimbursement" value="Yes" />
  422. <label for="rentalReimbursement"> Yes </label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="rentalReimbursement" name="rentalReimbursement" value="No" />
  423. <label for="rentalReimbursement"> No </label></span><span class="clearfix"></span>
  424. </div>
  425. </div>
  426. </li>
  427. <li class="form-line" id="id_28">
  428. <label class="form-label-left" id="towing_label" for="towing"> Towing & Labor </label>
  429. <div id="cid_28" class="form-input">
  430. <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio" id="towing" name="towing" value="Yes" />
  431. <label for="input_28_0"> Yes </label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="towing" name="towing" value="No" />
  432. <label for="towing"> No </label></span><span class="clearfix"></span>
  433. </div>
  434. </div>
  435. </li>
  436. <li id="cid_116" class="form-input-wide">
  437. <div class="form-header-group">
  438. <h3 id="header_116" class="form-header">
  439. Vehicle#1 Information
  440. </h3>
  441. </div>
  442. </li>
  443. <li class="form-line" id="id_4">
  444. <label class="form-label-left" id="v1year_label" for="v1year"> Year </label>
  445. <div id="cid_4" class="form-input">
  446. <input type="text" class="form-textbox" id="v1year" name="v1year" size="6" />
  447. </div>
  448. </li>
  449. <li class="form-line" id="id_151">
  450. <label class="form-label-left" id="v1make_label" for="v1make"> Make & Model </label>
  451. <div id="cid_151" class="form-input">
  452. <input type="text" class="form-textbox" id="v1make" name="v1make" size="30" />
  453. </div>
  454. </li>
  455. <li class="form-line" id="id_152">
  456. <label class="form-label-left" id="v1vin_label" for="v1vin"> VIN </label>
  457. <div id="cid_152" class="form-input">
  458. <input type="text" class="form-textbox" id="v1vin" name="v1vin" size="40" />
  459. </div>
  460. </li>
  461. <li id="cid_153" class="form-input-wide">
  462. <div class="form-header-group">
  463. <h3 id="header_153" class="form-header">
  464. Vehicle#2 Information
  465. </h3>
  466. </div>
  467. </li>
  468. <li class="form-line" id="id_154">
  469. <label class="form-label-left" id="v2year_label" for="v2year"> Year </label>
  470. <div id="cid_154" class="form-input">
  471. <input type="text" class="form-textbox" id="v2year" name="v2year" size="6" />
  472. </div>
  473. </li>
  474. <li class="form-line" id="id_155">
  475. <label class="form-label-left" id="v2make_label" for="v2make"> Make & Model </label>
  476. <div id="cid_155" class="form-input">
  477. <input type="text" class="form-textbox" id="v2make" name="v2make" size="30" />
  478. </div>
  479. </li>
  480. <li class="form-line" id="id_156">
  481. <label class="form-label-left" id="v2vin_label" for="v2vin"> VIN </label>
  482. <div id="cid_156" class="form-input">
  483. <input type="text" class="form-textbox" id="v2vin" name="v2vin" size="40" />
  484. </div>
  485. </li>
  486. <li id="cid_149" class="form-input-wide">
  487. <div class="form-header-group">
  488. <h3 id="header_149" class="form-header">
  489. Licensed Drivers
  490. </h3>
  491. </div>
  492. </li>
  493. <li class="form-line" id="id_42">
  494. <label class="form-label-left" id="otherDrivers_label" for="otherDrivers"> Are there any others in your household licensed to drive? </label>
  495. <div id="cid_42" class="form-input">
  496. <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio" id="otherDrivers" name="otherDrivers" value="Yes" />
  497. <label for="otherDrivers"> Yes </label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="otherDrivers" name="otherDrivers" value="No" />
  498. <label for="otherDrivers"> No </label></span><span class="clearfix"></span>
  499. </div>
  500. </div>
  501. </li>
  502. <li class="form-line" id="id_148">
  503. <label class="form-label-left" id="howMany_label" for="howMany"> If so, how many? </label>
  504. <div id="cid_148" class="form-input">
  505. <select class="form-dropdown" style="width:150px" id="howMany" name="howMany">
  506. <option> </option>
  507. <option value="1"<?= $howMany == '1' ? 'selected="selected"' : '' ?>> 1 </option>
  508. <option value="2"<?= $howMany == '2' ? 'selected="selected"' : '' ?>> 2 </option>
  509. <option value="3"<?= $howMany == '3' ? 'selected="selected"' : '' ?>> 3 </option>
  510. <option value="4"<?= $howMany == '4' ? 'selected="selected"' : '' ?>> 4 </option>
  511. <option value="5"<?= $howMany == '5' ? 'selected="selected"' : '' ?>> 5 </option>
  512. <option value="6"<?= $howMany == '6' ? 'selected="selected"' : '' ?>> 6 </option>
  513. </select>
  514. </div>
  515. </li>
  516. <li id="cid_161" class="form-input-wide">
  517. <div class="form-header-group">
  518. <h3 id="header_161" class="form-header">
  519. Credit Check (optional - insures more accurate quote)
  520. </h3>
  521. </div>
  522. </li>
  523. <li class="form-line" id="id_160">
  524. <label class="form-label-left" id="permission_label" for="permission"> I give permission for you to order credit. (optional) </label>
  525. <div id="cid_160" class="form-input">
  526. <div class="form-multiple-column"><span class="form-radio-item"><input type="radio" class="form-radio" id="permission" name="permission" value="Yes" />
  527. <label for="permission"> Yes </label></span><span class="clearfix"></span><span class="form-radio-item"><input type="radio" class="form-radio" id="permission" name="permission" value="No" />
  528. <label for="permission"> No </label></span><span class="clearfix"></span>
  529. </div>
  530. </div>
  531. </li>
  532. <li class="form-line" id="id_159">
  533. <label class="form-label-left" id="ssn_label" for="ssn"> SSN </label>
  534. <div id="cid_159" class="form-input">
  535. <input type="text" class="form-textbox" id="ssn" name="ssn" size="15" />
  536. </div>
  537. </li>
  538. <li class="form-line" id="id_145">
  539. <div id="cid_145" class="form-input-wide">
  540. <div id="text_145" class="form-html">
  541. <p>
  542. *indicates required fields.
  543. <br />
  544. <strong>
  545. <br />
  546. Disclaimer Notice -
  547. </strong>
  548. The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.
  549. </p>
  550. </div>
  551. </div>
  552. </li>
  553. <li class="form-line" id="id_109">
  554. <div id="cid_109" class="form-input-wide">
  555. <div style="text-align:center" class="form-buttons-wrapper">
  556. <button id="input_109" type="submit" class="form-submit-button form-submit-button-img">
  557. <img src="http://www.tracydriscoll.com/landingpages/next.png" alt="Submit Form" />
  558. </button>
  559. </div>
  560. </div>
  561. </li>
  562. <li style="display:none">
  563. Should be Empty:
  564. <input type="text" name="website" value="" />
  565. </li>
  566. </ul>
  567. </div>
  568. </form></p>
  569. </div>
  570. </div>
  571. <div class="bottomnav"> <span id="footer-LRG-text"><a href="http://www.tracydriscoll.com/autoinsurance.html">AUTO</a> | <a href="http://www.tracydriscoll.com/businessinsurance.html">BUSINESS</a> | <a href="http://www.tracydriscoll.com/lifeinsurance.html">LIFE</a> | <a href="http://www.tracydriscoll.com/homeinsurance.html">HOME</a></span><br />
  572. <span id="footer">© 2011 All Rights Reserved Tracy-Driscoll Insurance & Financial Services, 126 Main Street, Bristol CT 06010 &bull; 860.589.3434 &bull; <a href="http://www.tracydriscoll.com/privacy.html" target="_blank">PRIVACY POLICY</a><br />
  573. website powered by <a href="http://www.mbcinteractive.com/">MBC Interactive</a></span></div>
  574. </div>
  575. </body>
  576. </html>
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