<?

function my_get_post($name,$escape=false)
{
  $var_read = '';
  if (isset($_POST[$name]))
  {
    $var_read = $_POST[$name];
    if (get_magic_quotes_gpc()) $var_read=stripslashes($var_read);
	if ($escape) $var_read=htmlspecialchars($var_read,ENT_QUOTES);
  }
  return $var_read;
}


function form_1_count_spam($str)
{
$nb=0;
$word='http:';
if (stristr($str,$word)) $nb++;
$word='<';
if (stristr($str,$word)) $nb++;
$word='>';
if (stristr($str,$word)) $nb++;

return $nb;
}

function isEmail($str) 
{
  if(eregi("^[_a-z0-9-]+(\.[_a-z0-9-]+)*@[a-z0-9-]+(\.[a-z0-9-]+)*(\.[a-z]{2,4})$", $str)) 
    return true;
  else
    return false;
}
  $form_1_class='form_1_error';
$form_1_error='';
  $form_1_spam=0;
  
$form_1_td_1_class='form_1_info';
$form_1_td_1_error='&nbsp;';
$form_1_td_1_value='';

$form_1_td_2_class='form_1_info';
$form_1_td_2_error='&nbsp;';
$form_1_td_2_value='';

$form_1_td_3_class='form_1_info';
$form_1_td_3_error='&nbsp;';
$form_1_td_3_value='';

$form_1_td_4_class='form_1_info';
$form_1_td_4_error='&nbsp;';
$form_1_td_4_value='';

$form_1_td_5_class='form_1_info';
$form_1_td_5_error='&nbsp;';
$form_1_td_5_value='';


if ('uykwrrsy'==my_get_post('form_1_submit'))
{
$form_1_error_string='There are errors which need correction.';
$form_1_td_1_error_class='form_1_error';
$form_1_td_1_error_must='Error: This field is required!';
$form_1_td_1_error_spam='Error: http: < > are not allowed!';


$form_1_td_1_value=my_get_post('Name' ,true);
$form_1_body.='Name : '.my_get_post('Name')."\r\n";


if (''==trim(my_get_post('Name'))) {$form_1_td_1_class=$form_1_td_1_error_class; $form_1_td_1_error=$form_1_td_1_error_must; $form_1_error=$form_1_error_string;}
  

$form_1_td_1_spam=form_1_count_spam(my_get_post('Name'));
if ($form_1_td_1_spam>0)
{
  if ($form_1_td_1_class!=$form_1_td_1_error_class) {$form_1_td_1_class=$form_1_td_1_error_class; $form_1_td_1_error=$form_1_td_1_error_spam; $form_1_error=$form_1_error_string;}
  $form_1_spam += $form_1_td_1_spam;
}
  
$form_1_td_2_error_class='form_1_error';
$form_1_td_2_error_must='Error: This field is required!';
$form_1_td_2_error_validation='Error: This field must be an email!';
$form_1_td_2_error_spam='Error: http: < > are not allowed!';


$form_1_td_2_value=my_get_post('Email' ,true);
$form_1_body.='Email : '.my_get_post('Email')."\r\n";


if (''==trim(my_get_post('Email'))) {$form_1_td_2_class=$form_1_td_2_error_class; $form_1_td_2_error=$form_1_td_2_error_must; $form_1_error=$form_1_error_string;}
  

if ($form_1_td_2_class!=$form_1_td_2_error_class && ''!=trim(my_get_post('Email')) && !isEmail(my_get_post('Email'))) {$form_1_td_2_class=$form_1_td_2_error_class; $form_1_td_2_error=$form_1_td_2_error_validation; $form_1_error=$form_1_error_string;}
  

$form_1_td_2_spam=form_1_count_spam(my_get_post('Email'));
if ($form_1_td_2_spam>0)
{
  if ($form_1_td_2_class!=$form_1_td_2_error_class) {$form_1_td_2_class=$form_1_td_2_error_class; $form_1_td_2_error=$form_1_td_2_error_spam; $form_1_error=$form_1_error_string;}
  $form_1_spam += $form_1_td_2_spam;
}
  
$form_1_td_3_error_class='form_1_error';
$form_1_td_3_error_spam='Error: http: < > are not allowed!';


$form_1_td_3_value=my_get_post('Address' ,true);
$form_1_body.='Address : '.my_get_post('Address')."\r\n";


$form_1_td_3_spam=form_1_count_spam(my_get_post('Address'));
if ($form_1_td_3_spam>0)
{
  if ($form_1_td_3_class!=$form_1_td_3_error_class) {$form_1_td_3_class=$form_1_td_3_error_class; $form_1_td_3_error=$form_1_td_3_error_spam; $form_1_error=$form_1_error_string;}
  $form_1_spam += $form_1_td_3_spam;
}
  
$form_1_td_4_error_class='form_1_error';
$form_1_td_4_error_spam='Error: http: < > are not allowed!';


$form_1_td_4_value=my_get_post('Telephone' ,true);
$form_1_body.='Telephone : '.my_get_post('Telephone')."\r\n";


$form_1_td_4_spam=form_1_count_spam(my_get_post('Telephone'));
if ($form_1_td_4_spam>0)
{
  if ($form_1_td_4_class!=$form_1_td_4_error_class) {$form_1_td_4_class=$form_1_td_4_error_class; $form_1_td_4_error=$form_1_td_4_error_spam; $form_1_error=$form_1_error_string;}
  $form_1_spam += $form_1_td_4_spam;
}
  
$form_1_td_5_error_class='form_1_error';
$form_1_td_5_error_spam='Error: http: < > are not allowed!';


$form_1_td_5_value=my_get_post('Comments' ,true);
$form_1_body.='Comments : '.my_get_post('Comments')."\r\n";


$form_1_td_5_spam=form_1_count_spam(my_get_post('Comments'));
if ($form_1_td_5_spam>0)
{
  if ($form_1_td_5_class!=$form_1_td_5_error_class) {$form_1_td_5_class=$form_1_td_5_error_class; $form_1_td_5_error=$form_1_td_5_error_spam; $form_1_error=$form_1_error_string;}
  $form_1_spam += $form_1_td_5_spam;
}
  

if (''==trim($form_1_error) && 0==$form_1_spam)
{
$receiver='aboutus@needinsuranceforms.com';
$subject='Form Result -- Contact';

  $subject= substr($subject, 0, 255);
  $subject=str_replace("\n", " ", $subject);
  $subject=str_replace("\r", " ", $subject);

  $body=str_replace("\n.", "\n..", $form_1_body);



  if ($body!="")
  {
    $result=mail($receiver,$subject,$body,$header);
    if (!result)
    {
       echo 'ERROR: The PHP mail function mail($receiver,$subject,$body,$header); does not work properly on your server, please contact your web hosting.';
       exit;
    }
  }

  if ($result)
  {
    $url='http://NeedExpressChecks.com/feedback-thank-you.php';
    if (!headers_sent()){    
        header('Location: '.$url); exit;
    }else{                    
        echo '<script type="text/javascript">';
        echo 'window.location.href="'.$url.'";';
        echo '</script>';
        echo '<noscript>';
        echo '<meta http-equiv="refresh" content="0;url='.$url.'" />';
        echo '</noscript>'; exit;
    }	
    exit;
  }
}

  if (trim($form_1_error)) $form_1_error="<tr><td colspan=3 class='$form_1_class'>$form_1_error</td></tr>";
}
if ($form_1_spam >= 3)  sleep(20);
if ($form_1_spam >= 3) $form_1_td_1_value='';

if ($form_1_spam >= 3) $form_1_td_2_value='';

if ($form_1_spam >= 3) $form_1_td_3_value='';

if ($form_1_spam >= 3) $form_1_td_4_value='';

if ($form_1_spam >= 3) $form_1_td_5_value='';


?><!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN">
<html>
<head>
<title>NeedInsuranceForms.com</title>
<meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1" >
<meta name="description" content="NeedInsuranceForms.com provide Insurance Claim Forms for the Healthcare industry." >
<meta name="keywords" content="Need Insurance Forms" >
<meta name="GENERATOR" content="Ewisoft Website Builder eCommerce Software from http://www.ewisoft.com/" >
<link href="./usertpl/1corporate2/stylesheet.css" rel="stylesheet" type="text/css" ><link rel="stylesheet" type="text/css" href="./user/g-css-js/form-1.css" />
<script language="javascript" type="text/javascript" src="./user/g-css-js/form-1.js" ></script><script language="javascript" type="text/javascript" src="./user/g-css-js/common-form.js" ></script> </head>
<body bgcolor="#E6E6E6" leftmargin="0" topmargin="0" >
<TABLE WIDTH="780" BORDER="0" align="center" CELLPADDING="0" CELLSPACING="0" class="borderblack" >
<TR>
<TD>
<IMG SRC="./usertpl/1corporate2/spacer.gif" WIDTH="28" HEIGHT="1" ></TD>
<TD>
<IMG SRC="./usertpl/1corporate2/spacer.gif" WIDTH="162" HEIGHT="1" ></TD>
<TD>
<IMG SRC="./usertpl/1corporate2/spacer.gif" WIDTH="423" HEIGHT="1" ></TD>
<TD>
<IMG SRC="./usertpl/1corporate2/spacer.gif" WIDTH="167" HEIGHT="1" ></TD></TR>
<TR>
<TD COLSPAN="4" class="bannerbackground" ><table width="100%" border="0" cellpadding="10" cellspacing="0" >
<tr>
<td><a href="index.htm" ><img src="./user/cimage/NIF.png" width="700" height="80" border="0" ></a></td>
<td height="100%" ><span class="slogan" ></span></td>
<td><P>&nbsp;</P></td></tr></table></TD></TR>
<TR>
<TD COLSPAN="4" class="nav1background" ><table border="0" align="right" cellpadding="0" cellspacing="0" >
<tr>
<td><div align="right" ><img src="./usertpl/1corporate2/template_02b.gif" width="23" height="24" ></div></td>
<td background="./usertpl/1corporate2/nav2.jpg" ><p class="nav1" >
<a href="index.htm" target="_self" class="nav1" >Home</a><a href="site-map.htm" target="_self" class="nav1" >Site Map</a><a href="feedback.php" target="_self" class="nav1active" >Contact Us</a><a href="about-us.htm" target="_self" class="nav1" >About Us</a></p></td></tr></table></TD></TR>
<TR>
<TD COLSPAN="4" >
<IMG SRC="./usertpl/1corporate2/template_04.jpg" WIDTH="780" HEIGHT="15" ></TD></TR>
<TR>
<TD colspan="2" rowspan="2" valign="top" class="nav2container" ><table width="100%" border="0" cellspacing="0" cellpadding="0" >
<tr>
<td width="30" class="nav2left" >&nbsp;</td>
<td class="nav2background" >&nbsp;</td></tr>
<tr>
<td width="30" class="nav2left" >&nbsp;</td>
<td><table width="100%" border="0" cellpadding="5" cellspacing="0" >
<tr>
<td class="contentleft" ><DIV id="MyLiveChatContainer" align="center" ></DIV>
<script type="text/javascript" src="https://mylivechat.com/chatbutton.aspx?hccid=33067499" ></script>
<!--MyLiveChat end-->
<DIV align="center" >
<FORM method="post" name="MailingList" action="http://www.needstore.com/MailingList_subscribe.asp" >Join our mailing list!<BR><INPUT style="FONT-SIZE:11px;" maxLength="50" size="19" <name="emailaddress"><BR><INPUT name="Submit" value="Join Now" type="submit" ></DIV></FORM>
<P align="center" ><FONT size="3" face="Arial" ><STRONG><FONT color="#00a0f4" >Need</FONT><FONT color="#00ee38" >Forms</FONT><FONT color="#e60080" >Network</FONT></STRONG></FONT><BR><FONT size="2" face="Arial" >Stores accepts:</FONT><BR><img src="./user/cimage/payment.gif" width="96" height="92" border="0" >
<BR>and is verified<BR>and secured by:<BR></FONT></SPAN>
<ADDRESS></ADDRESS>
<DIV></DIV>
<DIV align="center" >
<ADDRESS align="center" ><img src="./user/cimage/AuthorizeSeal.gif" width="90" height="73" border="0" ></ADDRESS></DIV>
<DIV align="center" >
<ADDRESS align="center" ><img src="./user/cimage/VolSSL.gif" width="76" height="73" border="0" ></ADDRESS></DIV></td></tr></table></td></tr>
<tr>
<td class="nav2left" >&nbsp;</td>
<td class="nav2background" >&nbsp;</td></tr>
<tr>
<td class="nav2left" >&nbsp;</td>
<td class="nav2background" >&nbsp;</td></tr>
<tr>
<td class="nav2left" >&nbsp;</td>
<td class="nav2background" >&nbsp;</td></tr>
<tr>
<td class="nav2left" >&nbsp;</td>
<td class="nav2background" >&nbsp;</td></tr>
<tr>
<td class="nav2left" >&nbsp;</td>
<td class="nav2background" >&nbsp;</td></tr>
<tr>
<td class="nav2left" >&nbsp;</td>
<td class="nav2background" >&nbsp;</td></tr>
<tr>
<td class="nav2left" >&nbsp;</td>
<td class="nav2background" >&nbsp;</td></tr></table>
<table width="100%" border="0" cellspacing="0" cellpadding="0" >
<tr>
<td>&nbsp;</td></tr></table></TD>
<TD COLSPAN="2" valign="top" class="contentbackground" >
<table width="100%" border="0" cellspacing="0" cellpadding="0" >
<tr>
<td valign="top" class="contenttop" >&nbsp;</td></tr></table>
<table width="100%" border="0" cellspacing="0" cellpadding="5" >
<tr>
<td valign="top" ><H1>Feedback</H1>
<P>Please tell us what you think about our website, company, products, or services. If you provide us with your contact information, we will be able to reach you in case we have any questions..</P>
<P>
<form id="ewisoft_form-1" name="contact_us" method="post" action="#" onsubmit="return onsubmit_form_1();" >
<input type="hidden" name="form_1_submit" value="uykwrrsy" >
<table cellpadding="2" cellspacing="0" border="0" >
<? echo $form_1_error ?>
<tr><td class="form_1_td_1" >Name:</td><td class="form_1_td" ><input type="text" name="Name" value="<? echo $form_1_td_1_value ?>" onchange="validate_form_1_input_1(false);" /></td><td id="form_1_info_td_1" class="<? echo $form_1_td_1_class ?>" ><? echo $form_1_td_1_error ?></td></tr>
<tr><td class="form_1_td_2" >Email:</td><td class="form_1_td" ><input type="text" name="Email" value="<? echo $form_1_td_2_value ?>" onchange="validate_form_1_input_2(false);" /></td><td id="form_1_info_td_2" class="<? echo $form_1_td_2_class ?>" ><? echo $form_1_td_2_error ?></td></tr>
<tr><td class="form_1_td" >Address:</td><td class="form_1_td" ><textarea name="Address" ><? echo $form_1_td_3_value ?></textarea></td><td id="form_1_info_td_3" class="<? echo $form_1_td_3_class ?>" ><? echo $form_1_td_3_error ?></td></tr>
<tr><td class="form_1_td" >Telephone:</td><td class="form_1_td" ><input type="text" name="Telephone" value="<? echo $form_1_td_4_value ?>" onchange="validate_form_1_input_4(false);" /></td><td id="form_1_info_td_4" class="<? echo $form_1_td_4_class ?>" ><? echo $form_1_td_4_error ?></td></tr>
<tr><td class="form_1_td" >Comments:</td><td class="form_1_td" ><textarea name="Comments" ><? echo $form_1_td_5_value ?></textarea></td><td id="form_1_info_td_5" class="<? echo $form_1_td_5_class ?>" ><? echo $form_1_td_5_error ?></td></tr>
<tr><td align="center" class="form_1_td" colspan="2" ><input type="submit" value="Submit" /></td><td id="form_1_info_td_6" class="form_1_info" >&nbsp;</td></tr></table></form></P></td></tr></table></TD></TR></TABLE>
<table width="780" border="0" align="center" cellpadding="0" cellspacing="0" >
<tr>
<td><div align="center" ><P align="center" ><FONT size="2" face="Arial" >
<script language="JavaScript" ><!--
    document.write('&copy;' );
    document.write(' 2003 - ');
    document.write(new Date().getFullYear());
    document.write(' NeedFormsNetwork - All Rights Reserved.');
    //--></script></A></FONT>
<P style="MARGIN-TOP:0px;MARGIN-BOTTOM:0px;" align="center" ><FONT size="1" face="Arial" >Registered trademarks are owned by their respective companies</FONT>
<P style="MARGIN-TOP:0px;MARGIN-BOTTOM:0px;" align="center" ><FONT size="1" face="Arial" ><A style="COLOR:#000000;TEXT-DECORATION:none;" href="http://www.needforms.net/" >List of companies of the</A>
<B><FONT color="#00a0f4" >Need</FONT><FONT color="#00ee38" >Forms</FONT><FONT color="#e60080" >Network</FONT></B>.</FONT></P></div></td></tr></table>
<div align="center" class="copyright" style="text-decoration:blink;" ></div>
<p align="center" >&nbsp;</p></body></html>