"; $emailstr .= "Surname: " . $surname . "\n
"; $emailstr .= "State: " . $state . "\n
"; $emailstr .= "Postcode: " . $postCode . "\n
"; $emailstr .= "Day Phone: " . $dayPhone . "\n
"; $emailstr .= "Night Phone: " . $nightPhone . "\n
"; $emailstr .= "Email: " . $email . "\n
"; $emailstr .= "Best time: " . $bestTime . "\n
"; $emailstr .= "Gender: " . $gender . "\n
"; $emailstr .= "DOB: " . $dobday . "/" . $dobmonth . "/" . $dobyear . "\n
"; $emailstr .= "Height: " . $height . "\n
"; $emailstr .= "Weight: " . $weight . "\n
"; $emailstr .= "How much Life Insurace cover do you required: " . $coverRequired . "\n
"; $emailstr .= "Include TPD cover: " . $tpdCover . "\n
"; $emailstr .= "Include Trauma cover: " . $traumaCover . "\n
"; $emailstr .= "Include Income protection: " . $incomeProtection . "\n
"; $emailstr .= "Employment Status: " . $employmentStatus . "\n
"; $emailstr .= "When to paid: " . $whenPaid . "\n
"; $emailstr .= "For how long: " . $howLong . "\n
"; $emailstr .= "Occupation: " . $occupation . "\n
"; $emailstr .= "Work industry: " . $industry . "\n
"; $emailstr .= "Smoker: " . $smoker . "\n
"; $emailstr .= "Medication: " . $medication . "\n
"; $emailstr .= "Alzheimer's Disease: " . $tr11 . "\n
"; $emailstr .= "Asthma: " . $tr12 . "\n
"; $emailstr .= "Cancer: " . $tr13 . "\n
"; $emailstr .= "Cholesterol: " . $tr21 . "\n
"; $emailstr .= "Depression: " . $tr22 . "\n
"; $emailstr .= "Diabetes: " . $tr23 . "\n
"; $emailstr .= "Heart Disease: " . $tr24 . "\n
"; $emailstr .= "Hypertension: " . $tr25 . "\n
"; $emailstr .= "Kidney Disease: " . $tr31 . "\n
"; $emailstr .= "Liver Disease: " . $tr32 . "\n
"; $emailstr .= "Mental Illness: " . $tr33 . "\n
"; $emailstr .= "Pulmonary Disease: " . $tr34 . "\n
"; $emailstr .= "Stroke: " . $tr35 . "\n
"; $emailstr .= "Ulcers: " . $tr41 . "\n
"; $emailstr .= "Vascular Disease: " . $tr42 . "\n
"; $emailstr .= "Other: " . $tr43 . "\n
"; // To send HTML mail, the Content-type header must be set $headers = 'MIME-Version: 1.0' . "\r\n"; $headers .= 'Content-type: text/html; charset=iso-8859-1' . "\r\n"; // Additional headers $headers .= "From: QuoteRequest@{$_SERVER['SERVER_NAME']}\r\n"; $subject = "Quote Request"; $to = "tam@clubmigo.com"; $message = $emailstr; if(@mail($to, $subject, $message, $headers)){ //notify me echo "
"; echo "

"; echo "Your quote request has been sent. We will contact you shortly. Thank you."; echo "

"; //@mail($signupEmail, ucwords($firstname)." has joined", ucwords($firstname)." has joined", "From: signup@{$_SERVER['SERVER_NAME']}\r\n"); } else { echo "Email could not sent."; } } else { showForm(); } ?>

Please fill in the following information to request a quote: General Information
First Name*
Surname*
State of Residence	--Select-- NSW Queensland Victoria Tasmania SA WA NT ACT
Post Code
Daytime Telephone
Evening Telephone
Your Email Address*
Best Time to Call	--Select-- Daytime Evening
Gender*	Choose Gender Female Male
Date of Birth*	/ / (dd/mm/yyyy)
Height in cm*
Weigth in kg*
Please enter an amount for at least one of the types of cover listed below.
How much Term Life cover do you require?*		How much should you have?
Do you want to include a Lump Sum payable following Total & Permanent Disability.*		How much should you have?
Do you want to include a Lump sum payable on diagnosis of specified major medical conditions (trauma cover).*		How much should you have?
Do you want to include Income Protection cover? (Monthly benefit payable in the event of disablement))*		Most insurance companies limit the amount of Income Protection cover to a maximum of 75% of your taxable income.
What is your employment status?*
How quickly do you want to be on claim	14 days 30 days 60 days 90 days 120 days 240 days
How long do you want to be paid a benefit	2 years 5 years to age 65
What is your occupation?*
In what Industry do you work?*
Medical History
Are you a smoker?*	Yes No
Do you take any prescription medications? If yes, please state the name of medications?*
Have you received treatment for any of the following? (check any that apply):
Alzheimer's Disease Cholesterol Kidney Disease Ulcers Asthma Depression Liver Disease Vascular Disease Cancer Diabetes Mental Illness Other Hypertension Heart Disease Pulmonary Disease Stroke
Important: Please do NOT proceed to the next page if this is not a genuine enquiry. By proceeding you are confirming that the information you have provided is accurate and that you wish to receive comparative quotes and options .