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Go Back   Vista Forums > Misc Newsgroups > VB Script

Vista - HELP!

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Old 06-13-2009   #1 (permalink)
elliott4012


 
 

HELP!

I keep getting

CDO.Message.1 error '80040220'

The "SendUsing" configuration value is invalid.

/appraisal_form.asp, line 61



My code. Could someone help! I have tried so many combos. I know it
is the older ver. cdont. I have tried so many codes. I know it needs
to point to smtp, but I can not get the code to match all.

Thank you!





<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN">
<html>
<head>
<title> Assign a Claim.com - Appraisal Form</title>
<meta http-equiv="Content-Type" content="text/html;
charset=iso-8859-1">
<script language="JavaScript">
function validator(theForm) {
if (theForm.adjusters_email.value == "")
{
alert("You must enter an e-mail address!");
theForm.adjusters_email.focus();
return (false);
}
}
</script>

<!-- Beginning of ASP Form-Handler Script -->
<%
'Declare variables for the e-mail script
dim strAddr
dim replyTo
dim strSubject
dim strText

'Next, declare itsReady variable so we can trigger e-mail function
'only if user has entered an e-mail address. A real form would
'have a stringent error checking routine
dim itsReady
itsReady = ""
'Get input from the form and assign it to script variables
strAddr = Trim(Request.form("adjusters_email"))
if strAddr <> "" then
replyTo = cstr(strAddr)
end if

strSubject = "NEW DAMAGE APPRAISAL REQUEST"
strAdjname = Request.form("adjusters_name")

strText = "Company Name: " & Request.form("company_name")& vbCrLf &
"Adjuster's Name: " & Request.form("adjusters_name")& vbCrLf & "Phone:
" & Request.form("phone") & vbCrLf & "Fax: " & Request.form("fax") &
vbCrLf & "Adjuster's Email: " & Request.form("adjusters_email") &
vbCrLf & "File #: " & Request.form("file") & vbCrLf & "Policy #: " &
Request.form("policy") & vbCrLf & "Date of Loss: " & Request.form
("date_of_loss") & vbCrLf & "Insured: " & Request.form("insured") &
vbCrLf & "Claimant: " & Request.form("claimant") & vbCrLf & "Address
1 :" & Request.form("address_1") & vbCrLf & "Address 2: " &
Request.form("address_2") & vbCrLf & "City: " & Request.form("city") &
vbCrLf & "State: " & Request.form("state") & vbCrLf & "Zip: " &
Request.form("zip") & vbCrLf & "Country: " & Request.form("country") &
vbCrLf & "Home Phone: " & Request.form("home_phone") & vbCrLf & "Work
Phone:" & Request.form("work_phone") & vbCrLf & "VECHICLE
INFORMATION:" & vbCrLf & "Year: " & Request.form("year") & vbCrLf &
"Make: " & Request.form("make") & vbCrLf & "Model: " & Request.form
("model") & vbCrLf & "Color: " & Request.form("color") & vbCrLf &
"Tag #: " & Request.form("tag") & vbCrLf & "VIN: " & Request.form
("vin") & vbCrLf & "point of Impact / Loss: " & Request.form
("point_of_impact") & vbCrLf & "Special Instructions: " & Request.form
("special_instructions") & vbCrLf & "Vehicle Driveable: " &
Request.form("vehicle_driveable") & vbCrLf & "Vehicle Location: " &
Request.form("vehicle_location") & vbCrLf & "Location Phone: " &
Request.form("location_phone") & vbCrLf & "Shop Estimates: " &
Request.form("shop_estimates") & vbCrLf & "Shop 1: " & Request.form
("shop_1") & vbCrLf & "Shop 2: " & Request.form("shop_2") & vbCrLf &
"Shop 3: " & Request.form("shop_3") & vbCrLf & "Shop 4: " &
Request.form("shop_4") & vbCrLf & "APPRAISAL INSTRUCTIONS" & vbCrLf &
"Appraisal Instructions: " & Request.form("appraisal_instructions") &
vbCrLf & "Call Back To: " & Request.form("call_adjuster") &
Request.form("call_other") & vbCrLf & "If Repairable Loss: " &
Request.form("if_repairable_loss") & vbCrLf & "If Total Loss: " &
Request.form("if_total_loss")

'Note: use vbCrLf (as above) to add line breaks in e-mail message
'Now trigger e-mail function if submitted with a non-blank user_email

if replyTo <> "" then itsReady = send_email()

'The send_email function formats and sends the e-mail

function send_email()
'Create an object or container for your mail
Dim objMail
Set objMail = Server.CreateObject("CDO.Message")
'Format the e-mail using fields from your HTML form
objMail.To = "allstarappraisals@xxxxxx"
objMail.From = Request.form("adjusters_email")
'The From address is a fake address to alert you to
'the origin of the email. You will not reply to it.
objMail.ReplyTo = replyTo
'replyTo is the user_email address from the form
objMail.Subject = strSubject
objMail.TextBody = strText
objMail.Send 'comment out to test script without sending mail
'Release system resources
Set objMail = Nothing
'Book example includes following line; replaced by a Javascript alert
box
'Response.Write "<h3>Thank you for using e-mail!</h3>"
if err.number > 0 then
response.write "Errors were encountered in sending your e-mail
message. "&_
"Please try again, or contact the <a
href='mailto:allstarappraisals@xxxxxx'>webmaster</a>"
else
%>
<script language="JavaScript">
<!--
alert("Your e-mail has been sent!\nThank you for using our e-mail
form!");
//-->
</script>
<%
end if
end function
%>
<!-- End of ASP Form-Handler Script -->
</head>

<body leftmargin="0" topmargin="0" marginwidth="0" marginheight="0">
<table width="100%" height="100%" border="0" align="center"
cellpadding="0" cellspacing="0">
<tr>
<td align="center" valign="middle" bgcolor="#000066">
<table width="100" height="434" border="0" cellpadding="0"
cellspacing="0">
<tr>
<td><table width="10" border="0" cellpadding="0"
cellspacing="0">
<tr>
<td height="10" colspan="3" align="center"
valign="top"><img src="/Images/header.jpg" width="780" height="106"></
td>
</tr>
<tr bgcolor="#C80722">
<td height="10" colspan="3"> <table width="100%"
border="0" cellspacing="0" cellpadding="0">
<tr>
<td width="15%"> <div align="center"><a href="/
index.htm"><img src="/Images/home.jpg" width="55" height="15"
border="0"></a></div></td>
<td width="21%"><div align="center"><a href="/
about_us.htm"><img src="/Images/about.jpg" width="89" height="15"
border="0"></a></div></td>
<td width="20%"><div align="center"><a href="/
sevices.htm"><img src="/Images/services.jpg" width="86" height="15"
border="0"></a></div></td>
<td width="20%"><div align="center"><a href="/
contact.htm"><img src="/Images/contact.jpg" width="104" height="15"
border="0"></a></div></td>
<td width="25%"> <div align="center"><a href="/
appraisal_form.htm"><img src="/Images/apparasal.jpg" width="142"
height="15" border="0"></a></div></td>
</tr>
</table></td>
</tr>
<tr>
<td width="1" height="265" align="center" valign="top"
bgcolor="#FFFFFF">
<div align="center"></div></td>
<td width="778" align="center" valign="top"
bgcolor="#3C457C">
<div align="center">
<table width="82%" border="0" cellspacing="0"
cellpadding="0">
<tr>
<td align="center" valign="top">
<form method="post"
action="appraisal_form.asp" onSubmit="return validator(this)">
<table border="0">
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">Company
Name</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">
<input name="company_name"
type="text" size="50">
</font></td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">Adjusters
Name</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">
<input name="adjusters_name"
type="text" id="adjusters_name" size="50">
</font></td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">Phone</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">
<input name="phone" type="text"
id="phone">
</font></td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">Fax</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">
<input name="fax" type="text"
id="fax">
</font></td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">Adjusters
Email</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">
<input name="adjusters_email"
type="text" id="adjusters_email" size="50">
</font></td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">&nbsp;</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">&nbsp;</font></
td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">&nbsp;</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">Claim
Information</font></td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">Assigned
to:</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">Allstar
Appraisals</font></td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">File
#:</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">
<input name="file" type="text"
id="file" size="50">
</font></td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">Policy
#:</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">
<input name="policy" type="text"
id="policy" size="50">
</font></td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">Date
of Loss:</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">
<input name="date_of_loss"
type="text" id="date_of_loss">
</font></td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">Insured:</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">
<input name="insured" type="text"
id="insured" size="50">
</font></td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">Claimant:</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">
<input name="claimant" type="text"
id="claimant" size="50">
</font></td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">Address
(Line 1):</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">
<input name="address_1" type="text"
id="address_1" size="50">
</font></td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">Address
(Line 2):</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">
<input name="address_2" type="text"
id="address_2" size="50">
</font></td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">City:</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">
<input name="city" type="text"
id="city" size="50">
</font></td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">State:</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">
<input name="state" type="text"
id="state" size="2" maxlength="2">
</font></td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">Zip
Code:</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">
<input name="zip" type="text"
id="zip">
</font></td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">Country:</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">
<input name="country" type="text"
id="country" size="50">
</font></td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">Home
Phone:</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">
<input name="home_phone" type="text"
id="home_phone">
</font></td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">Work
Phone:</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">
<input name="worK_phone" type="text"
id="work_phone">
</font></td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">&nbsp;</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">Vehicle
Information</font></td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">Year:</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">
<input name="year" type="text"
id="year" size="4">
</font></td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">Make:</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">
<input name="make" type="text"
id="make">
</font></td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">Model:</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">
<input name="model" type="text"
id="model">
</font></td>
</tr>
<tr>
<td height="22" width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">Color:</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">
<input name="color" type="text"
id="color">
</font></td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">Tag
#:</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">
<input name="tag" type="text"
id="tag">
</font></td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">VIN:</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">
<input name="vin" type="text"
id="vin">
</font></td>
</tr>
<tr>
<td valign="top" width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">Point
of Impact / Loss</font></div>
</td>
<td width="417" ><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">
<textarea name="point_of_impact"
cols="50" rows="3" id="point_of_impact"></textarea>
</font></td>
</tr>
<tr>
<td valign="top" width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">Special
Instructions:</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">
<textarea
name="special_instructions" cols="50" rows="10"
id="special_instructions"></textarea>
</font></td>
</tr>
<tr>
<td height="16" width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">&nbsp;</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">&nbsp;
</font></td>
</tr>
<tr>
<td height="16" width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">Vehicle
Driveable:</font></div>
</td>
<td width="417">
<p> <font color="#FFFFFF" size="4">
<label>
<font face="Verdana, Arial,
Helvetica, sans-serif">
<input name="vehicle_driveable"
type="radio" value="Yes" checked>
Yes</font></label> <font
face="Verdana, Arial, Helvetica, sans-serif">
<label>
<input type="radio"
name="vehicle_driveable" value="No">
No</label> </font></font> </p>
</td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">Vehicle
Location:</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">
<input name="vehicle_location"
type="text" id="vehicle_location" size="50">
</font></td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">Location
Phone:</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">
<input name="location_phone"
type="text" id="location_phone">
</font></td>
</tr>
<tr>
<td height="21" width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">Shop
Estimates:</font></div>
</td>
<td width="417">
<p> <font color="#FFFFFF" size="4">
<label>
<font face="Verdana, Arial,
Helvetica, sans-serif">
<input name="shop_estimates"
type="radio" value="Yes" checked>
Yes</font></label> <font
face="Verdana, Arial, Helvetica, sans-serif">
<label>
<input type="radio"
name="shop_estimates" value="No">
No</label> </font></font> </p>
</td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">Name
of Shop(s)</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">
<input name="shop _1" type="text"
id="shop_1" size="50">
</font></td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">&nbsp;</font></div>
</td>
<td width="417"> <font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">
<input name="shop_2" type="text"
id="shop_22" size="50">
</font></td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">&nbsp;</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">
<input name="shop_3" type="text"
id="shop_32" size="50">
</font></td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">&nbsp;</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">
<input name="shop_4" type="text"
id="shop_42" size="50">
</font></td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">&nbsp;</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">&nbsp;</font></
td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">&nbsp;</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">Appraisal
Instructions</font></td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">
<input type="radio"
name="appraisal_instructions" value="Obtain price from shop of owners
choice">
</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">Obtain
agreed price with shop of owners
choice</font></td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">
<input
name="appraisal_instructions" type="radio" value="Appraise damage
only">
</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">Appraise
damage only. Do not obtain agreed
price.</font></td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">Other&nbsp;
</font></div>
</td>
<td width="417"> <font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">
<input name="other" type="text"
id="other" size="50">
</font></td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">&nbsp;</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">&nbsp;</font></
td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">Call
Back To:</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">
<input type="checkbox"
name="call_adjuster" value="Call back to Adjuster" checked>
Adjuster </font></td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">Other</font></div>
</td>
<td width="417"> <font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">
<input name="call_other" type="text"
id="call_other" size="50">
</font></td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">If
repairable loss</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">
<input name="if_repairable_loss"
type="radio" value="Call if repairable loss" checked>
Yes
<input type="radio"
name="if_repairable_loss" value="Do not call if repairable loss">
No</font></td>
</tr>
<tr>
<td width="213">
<div align="right"><font
color="#FFFFFF" size="4" face="Verdana, Arial, Helvetica, sans-
serif">If
total loss:</font></div>
</td>
<td width="417"><font color="#FFFFFF"
size="4" face="Verdana, Arial, Helvetica, sans-serif">
<input name="if_total_loss"
type="radio" value="Call if total loss" checked>
Yes
<input name="if_total_loss"
type="radio" value="Do not call if total loss">
No</font></td>
</tr>
<tr>
<td width="213">
<div align="right"></div>
</td>
<td width="417">&nbsp;</td>
</tr>
<tr>
<td width="213">
<div align="left"></div>
</td>
<td height="40" width="417">
<input type="submit" value="Submit"
name="submit">
&nbsp;
<input type="reset" value="Clear"
name="reset">
</td>
</tr>
</table>
</form></td>
</tr>
</table>
</div></td>
<td width="1" align="right" valign="middle"
bgcolor="#FFFFFF"><div align="center"></div></td>
</tr>
<tr>
<td height="10" colspan="3" bgcolor="#3C457C"><div
align="right"><img src="/Images/copyright.jpg" width="350"
height="15"></div></td>
</tr>
<tr>
<td height="25" colspan="3" valign="bottom"><img src="/
Images/footer.jpg" width="780" height="25"></td>
</tr>
</table></td>
</tr>
</table></td>
</tr>
</table>
</body>
</html>

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