Phone Number : $phone
Content : $content
Address : $address"; // To send HTML mail, the Content-type header must be set // 관리자 $to = "pom@21insurance.com"; //$to = "chanyong.lee@gmail.com"; $eol="\r\n"; $headers .= "From: 한인종합보험 ".$eol; $headers .= "Reply-To: $name <$email>".$eol; $headers .= "Return-Path: $name <$email>".$eol; // these two to set reply address $headers .= "Message-ID: <".$now." TheSystem@".$_SERVER['SERVER_NAME'].">".$eol; $headers .= "X-Mailer: PHP v".phpversion().$eol; // These two to help avoid spam-filters $headers .= 'Content-type: text/html; charset=UTF-8' . "\r\n"; // Mail it $result = mail($to, $subject, $message, $headers); Misc::jvAlert("Your request has been successfully submitted. \\n\\n An agent will contact you within 24 hours. \\n\\nThank you.","location.replace('index.php')"); exit; } else { echo "Fail"; exit; } } include "inc_top.php"; ?>

 Auto (Personal)
Please type a question mark(?) if you don't know the answer, and we will explain to you when we contact you.

 Applicant's Name * :  
 Address * :  
 Telephone Number * :  
 Email * :  
 List of Drivers:    
Name DOB License # Issue State SSN Marital Status
 Vehicle Information :    
Year Make Model VIN #
 Full Coverage Needed :   Yes No (Liability Only)
 Desired Liability Limit :   State Minimum $50,000/$100,000 $100,000/$300,000 Other
 Desired Comprehension and
 Collision Deductible :
  $500 $750 $1,000
 Current Auto Insurance Carrier :  
 Expiration Date of Current
 Insurance Policy :
 
 Loss/Claim in the last 3 year :   Yes No Loss
 Education :  
 Homeowner or Rent :   Owner Rent
 Additional Information :