Web Form

samg914 · June 8, 2010, 1:08pm

Once my form sends it renders a message that says either “Thank you. Your auto quote request has been sent.” or “Thank you. Your homeowners quote request has been sent.” or both, depending on which parts of the form have been filled out. However, I need 2 other things to happen in addition to this.

A) when the form successfully sends, the fields still have the content that the user put in them. I need the content to be cleared. B) I need the two checkboxes to automatically uncheck them selves and the form fields to collapse.

URL: http://www.searchtransparencysem.com/projects/wedgwood/multi-insurance-quote-test.php

Thanks in Advance,

Samuel

wackyjoe · June 8, 2010, 1:21pm

Post some code.

samg914 · June 8, 2010, 2:07pm

This is the entire form:

<form action="multi-insurance-quote-test.php" method="post" id="auto-form">
<div id="form-top">
<h2>Save time &amp; Money</h2>
<h3>Fillout 1 form and recieve 2 quotes</h3>
<strong>Please select the insurance(s) for which you would like to receive a quote(s).</strong><br/>
<br/>
<input type="checkbox" name="includeAutoQuote"
 id="includeAutoQuote" value="includeAutoQuote" <?php if( isset($_POST['includeAutoQuote']) ) echo 'checked'; ?> />
Auto&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
<input type="checkbox" name="includeHomeQuote" id="includeHomeQuote" value="includeHomeQuote" <?php if( isset($_POST['includeHomeQuote']) ) echo 'checked'; ?> />
Homeowners/Renters </div> <div id="form-bottom"> <div id="form-validation">

<?php
if ( isset($_POST['includeAutoQuote']) && ($_POST['includeAutoQuote'] == 'includeAutoQuote')  )

{
	
	$name = $_POST['name'];
	$phone = $_POST['phone'];
	$address = $_POST['address'];
	$email = $_POST['email'];
	$license_number = $_POST['license_number'];
	$dob = $_POST['dob'];
	$first_license = $_POST['first_license'];
	$vin_number = $_POST['vin_number'];
	$vehicle_make = $_POST['vehicle_make'];
	$vehicle_model = $_POST['vehicle_model'];	
	$vehicle_year = $_POST['vehicle_year'];
	$uninsured_motorist = $_POST['uninsured_motorist'];
	$property_damage = $_POST['property_damage'];
	$bodily_injury = $_POST['bodily_injury'];
	$underinsured_motorist = $_POST['underinsured_motorist'];
	$mileage = $_POST['mileage'];
	$city_garaged = $_POST['city_garaged'];

	$errorstring = "";

if (!$name)
	$errorstring = $errorstring."Name<br>";

if (!$phone)
 	$errorstring = $errorstring."Phone #<br>";
	
if (!$address)
 	$errorstring = $errorstring."Address<br>";
	
if (!$email)
 	$errorstring = $errorstring."Email<br>";

if (!$license_number)
	$errorstring = $errorstring."License Number<br>";

if (!$dob)
 	$errorstring = $errorstring."D.O.B.<br>";
	
if (!$first_license)
 	$errorstring = $errorstring."Year you received your first license<br>";
	
if (!$vin_number)
 	$errorstring = $errorstring."VIN Number<br>";
	
if (!$vehicle_make)
	$errorstring = $errorstring."Vehicle Make<br>";

if (!$vehicle_model)
 	$errorstring = $errorstring."Vehicle Model<br>";
	
if (!$vehicle_year)
 	$errorstring = $errorstring."Vehicle Year<br>";
	
 if (!$uninsured_motorist)
 	$errorstring = $errorstring."Uninsured Motorist<br>";
	
if (!$property_damage)
 	$errorstring = $errorstring."Property Damage<br>";
	
if (!$bodily_injury)
 	$errorstring = $errorstring."Bodily Injury<br>";

if (!$underinsured_motorist)
 	$errorstring = $errorstring."Underinsured Motorist<br>";
	
if (!$mileage)
 	$errorstring = $errorstring."Mileage<br>";
	
if (!$city_garaged)
 	$errorstring = $errorstring."What city is the vehicle garaged in?t<br>";

if ($errorstring!="")
	echo "<h3>Please fill out the following Auto form fields</h3>$errorstring<br>";
  else
  {
  //run code
  echo "<h3>Thank you. Your auto quote request has been sent.</h3>";
  }
}
?>

<?php
if ( isset($_POST['includeHomeQuote']) && ($_POST['includeHomeQuote'] == 'includeHomeQuote')  )

{

$name = $_POST['name'];
$phone = $_POST['phone'];
$address = $_POST['address'];
$email = $_POST['email'];
$type_of_insurance = $_POST['type_of_insurance'];
$number_of_units = $_POST['number_of_units'];
$square_footage = $_POST['square_footage'];
$year_built = $_POST['year_built'];
$current_insurance_company = $_POST['current_insurance_company'];
$amps = $_POST['amps'];
$does_owner_live_on_property = $_POST['does_owner_live_on_property'];
$new_or_existing_residence = $_POST['new_or_existing_residence'];
$type_of_structure = $_POST['type_of_structure'];
$heating_source = $_POST['heating_source'];
$coverage_cancelled = $_POST['coverage_cancelled'];

$errorstring = "";

if (!$name)
	$errorstring = $errorstring."Name<br>";

if (!$phone)
 	$errorstring = $errorstring."Phone #<br>";
	
if (!$address)
 	$errorstring = $errorstring."address<br>";
	
if (!$email)
 	$errorstring = $errorstring."email<br>";
	
if (!$type_of_insurance)
	$errorstring = $errorstring."Type of insurance<br>";

if (!$number_of_units)
 	$errorstring = $errorstring."Number of units<br>";
	
if (!$square_footage)
 	$errorstring = $errorstring."Square footage<br>";
	
if (!$year_built)
 	$errorstring = $errorstring."Year built<br>";
	
if (!$current_insurance_company)
 	$errorstring = $errorstring."Current insurance company<br>";
	
if (!$amps)
 	$errorstring = $errorstring."I verify that the electrical system is circuit breakers and at least 100 amps<br>";
	
if (!$does_owner_live_on_property)
 	$errorstring = $errorstring."Does the owner live on the property?<br>";
	
if (!$new_or_existing_residence)
 	$errorstring = $errorstring."New or existing property?<br>";
	
if (!$type_of_structure)
	$errorstring = $errorstring."Type of structure<br>";

if (!$heating_source)
 	$errorstring = $errorstring."Heating source<br>";
	
if (!$coverage_cancelled)
 	$errorstring = $errorstring."Has your coverage been cancelled in the last three years?<br>";

if ($errorstring!="")
	echo "<h3>Please fill out the following Homeowners form fields</h3>$errorstring<br>";
  else
  {
  //run code
  echo "<h3>Thank you. Your homeowners quote request has been sent.</h3>";
  }
}
?>
<?php
/* Subject and Email Variables */

	$subject = 'Insurance Quote Request';
	$to = 'samuel@searchtransparencysem.com';
	
/* Gathering Data Variables */	

	$type_of_insurance = $_POST['type_of_insurance'];
	$name = $_POST['name'];
	$address = $_POST['address'];
	$ssn = $_POST['ssn'];
	$phone = $_POST['phone'];
	$email = $_POST['email'];
	$number_of_units = $_POST['number_of_units'];
	$square_footage = $_POST['square_footage'];
	$year_built = $_POST['year_built'];
	$city_garaged = $_POST['city_garaged'];
	$pets = $_POST['pets'];
	$updates = $_POST['updates'];
	$current_insurance_company = $_POST['current_insurance_company'];
	$why_was_policy_cancelled = $_POST['why_was_policy_cancelled'];
	$paid_losses = $_POST['paid_losses'];
	$amps = $_POST['amps'];
	$does_owner_live_on_property = $_POST['does_owner_live_on_property'];
	$new_or_existing_residence = $_POST['new_or_existing_residence'];
	$type_of_structure = $_POST['type_of_structure'];
	$heating_source = $_POST['heating_source'];
	$coverage_cancelled = $_POST['coverage_cancelled'];
	$license_number = $_POST['license_number'];
	$dob = $_POST['dob'];
	$first_license = $_POST['first_license'];
	$vin_number = $_POST['vin_number'];
	$vehicle_make = $_POST['vehicle_make'];
	$vehicle_model = $_POST['vehicle_model'];
	$vehicle_year = $_POST['vehicle_year'];
	$uninsured_motorist = $_POST['uninsured_motorist'];
	$property_damage = $_POST['property_damage'];
	$bodily_injury = $_POST['bodily_injury'];
	$medical_payments = $_POST['medical_payments'];
	$collision_deductible = $_POST['collision_deductible'];
	$limited_collision_deductible = $_POST['limited_collision_deductible'];
	$comprehensive_deductible = $_POST['comprehensive_deductible'];
	$substitute_transportation = $_POST['substitute_transportation'];
	$towing_and_labor = $_POST['towing_and_labor'];
	$underinsured_motorist = $_POST['underinsured_motorist'];
	$mileage = $_POST['mileage'];
	$alarm = $_POST['alarm'];
	$airbags = $_POST['airbags'];
	$lojack = $_POST['lojack'];
	$onstar = $_POST['onstar'];
	$auto_remarks = $_POST['auto_remarks'];
	$home_remarks = $_POST['home_remarks'];
	$body = <<<EOD
<br><hr><br>
<h1>Insurance Quote Request</h1>
<h1>Homeowners/Renters Quote Request</h1><br>
<h2>Personal Information</h2>
Name: $name <br>
Address: $address <br>
SSN: $ssn <br>
Phone: $phone <br>
Email: $email <br>
<h2>Residence</h2>
Type of insurance: $type_of_insurance <br>
Number of units: $number_of_units <br>
Square footage: $square_footage <br>
Year built: $year_built <br>
Pets: $pets <br>
Updates: $updates <br>
Current insurance company: $current_insurance_company <br>
If policy was cancelled, why?: $why_was_policy_cancelled <br>
Paid losses: $paid_losses <br>
I verify that the electrical system is circuit breakers and at least 100 amps: $amps <br>
Does the owner live on the property?: $does_owner_live_on_property <br>
New or existing property?: $new_or_existing_residence <br>
Type of structure: $type_of_structure <br>
Heating source: $heating_source <br>
Has your coverage been cancelled in the last three years?: $coverage_cancelled <br>
Remarks: $home_remarks <br>
<h1>Auto Quote Request</h1><br><br>
<h2>Driver Information</h2>
License number: $license_number <br>
D.O.B.: $dob <br>
Year you received your first license: $first_license <br><br>
<h2>Vehicle Information</h2>
VIN number: $vin_number <br>
Make: $vehicle_make <br>
Model: $vehicle_model <br>
Year: $vehicle_year <br>
<h2>Coverages</h2>
Uninsured Motorist: $uninsured_motorist <br>
Property Damage: $property_damage <br>
Bodily Injury: $bodily_injury <br>
Medical Payments: $medical_payments <br>
Collison Deductible: $collision_deductible <br>
Limitied Collison Deductible: $limited_collision_deductible <br>
Comprehensive Deductible: $comprehensive_deductible <br>
Substitute Transportation: $substitute_transportation <br>
Towing and Labor: $towing_and_labor <br>
Underinsured Motorist: $underinsured_motorist <br>
Mileage: $mileage <br>
What city is the vehicle garaged in?: $city_garaged <br><br>
<h3>Options that your vehicle is equiped with</h3>
Alarm: $alarm <br>
Airbags: $airbags <br>
LoJack: $lojack <br>
OnStar: $onstar <br>
Remarks: $auto_remarks <br>
EOD;

	$headers = "From: $email\\r\
";
	$headers = "Content-type: text/html\\r\
";
mail($to,$subject,$body,$headers);

  

?>
</div> <div id="top-top-form"> <div id="form-bottom-left">
<label>Name*<br/>
<input name="name" type="text" class="text-field-home-narrow" id="name" value="<?php echo $name; ?>" />
</label>
<br/>
<label>Address*<br/>
<input name="address" type="text" class="text-field-home-narrow" id="address" value="<?php echo $address; ?>" />
</label>
<br/>
</div> <div id="form-bottom-right">
<label>Phone #*<br/>
<input name="phone" type="text" class="text-field-home-narrow" id="phone" value="<?php echo $phone; ?>" />
</label>
<br/>
<label>Email*<br/>
<input name="email" type="text" class="text-field-home-narrow" id="email" value="<?php echo $email; ?>" />
</label>
<br/>
</div> </div> <div id="auto">
<h2>Auto</h2>
<div id="form-bottom-left">
<label>License #*<br/>
<input name="license number" type="text" class="text-field-home-narrow" id="license number" value="<?php echo $license_number; ?>" />
</label>
<br/>
<label>D.O.B.*<br/>
<input name="dob" type="text" class="text-field-home-narrow" id="dob" value="<?php echo $dob; ?>" />
</label>
</div> <div id="form-bottom-right">
<label>Year you receved your first license*<br/>
<input name="first license" type="text" class="text-field-home-narrow" id="first license" value="<?php echo $first_license; ?>" />
</label>
<br/>
<label>VIN # (listed on  vehicle registration)*<br/>
<input name="vin number" type="text" class="text-field-home-narrow" id="vin number" value="<?php echo $vin_number; ?>" />
</label>
</div> <div id="form-bottom-bottom"><br/>
<strong>Vehicle</strong><br/>
<br/>
<label>Make*
<input name="vehicle make" type="text" class="text-field-home-short" id="vehicle make" value="<?php echo $vehicle_make; ?>" />
</label>
Model*
<input name="vehicle model" type="text" class="text-field-home-short" id="vehicle model" value="<?php echo $vehicle_model; ?>" />
</label>
<label>Year*
<input name="vehicle year" type="text" class="text-field-home-short" id="vehicle year" value="<?php echo $vehicle_year; ?>" />
</label>
<br/>
<br/>
<label>What city is your vehicle garaged in?*<br/>
<input name="city garaged" type="text" class="text-field-home-narrow" id="city garaged" value="<?php echo $city_garaged; ?>" />
</label>
<br/>
<label>Total mileage on vehicle?*<br/>
<input name="mileage" type="text" class="text-field-home-narrow" id="mileage" value="<?php echo $mileage; ?>" />
</label>
<br/>
<br/>
<h3>Please select the amount(s) of your current/desired coverages</h3>
<strong>Uninsured Motorist</strong>*<br/>
<label>
<input type="radio" name="uninsured motorist" value="$20,000/$40,000" id="uninsured motorist" />
$20,000/$40,000</label>
<br/>
<label>
<input type="radio" name="uninsured motorist" value="$50,000/$100,000" id="uninsured motorist" />
$50,000/$100,000</label>
<br/>
<label>
<input type="radio" name="uninsured motorist" value="$100,000/$300,000" id="uninsured motorist" />
$100,000/$300,000</label>
<br/>
<label>
<input type="radio" name="uninsured motorist" value="$250,000/$500,000" id="uninsured motorist" />
$250,000/$500,000</label>
<br/>
<br/>
<strong>Property Damage</strong>*<br/>
<label>
<input type="radio" name="property damage" value="$100,000" id="property damage" />
$100,000</label>
<br/>
<br/>
<strong>Bodily Injury</strong>*<br/>
<label>
<input type="radio" name="bodily injury" value="$20,000/$40,000" id="bodily injury" />
$20,000/$40,000</label>
<br/>
<label>
<input type="radio" name="bodily injury" value="$50,000/$100,000" id="bodily injury" />
$50,000/$100,000</label>
<br/>
<label>
<input type="radio" name="bodily injury" value="$100,000/$300,000" id="bodily injury" />
$100,000/$300,000</label>
<br/>
<label>
<input type="radio" name="bodily injury" value="$250,000/$500,000" id="bodily injury" />
$250,000/$500,000</label>
<br/>
<br/>
<strong>Medical Payments (optional)</strong><br/>
<label>
<input type="radio" name="medical payments" value="none" id="medical payments" />
None</label>
<br/>
<label>
<input type="radio" name="medical payments" value="$5,000" id="medical payments" />
$5,000</label>
<br/>
<label>
<input type="radio" name="medical payments" value="$10,000" id="medical payments" />
$10,000</label>
<br/>
<label>
<input type="radio" name="medical payments" value="$15,000" id="medical payments" />
$15,000</label>
<br/>
<label>
<input type="radio" name="medical payments" value="$20,000" id="medical payments" />
$20,000</label>
<br/>
<label>
<input type="radio" name="medical payments" value="$25,000" id="medical payments" />
$25,000</label>
<br/>
<br/>
<strong>Collison Deductible (optional)</strong><br/>
<label>
<input type="radio" name="collision deductible" value="none" id="collision deductible" />
None</label>
<br/>
<label>
<input type="radio" name="collision deductible" value="$300" id="collision deductible" />
$300</label>
<br/>
<label>
<input type="radio" name="collision deductible" value="$500" id="collision deductible" />
$500</label>
<br/>
<label>
<input type="radio" name="collision deductible" value="$1000" id="collision deductible" />
$1000</label>
<br/>
<br/>
<strong>Limited Collison Deductible (optional)</strong><br/>
<label>
<input type="radio" name="limited collison deductible" value="none" id="limited collison deductible" />
None</label>
<br/>
<label>
<input type="radio" name="limited collison deductible" value="$0" id="limited collison deductible" />
$0</label>
<br/>
<label>
<input type="radio" name="limited collison deductible" value="$300" id="limited collison deductible" />
$300</label>
<br/>
<label>
<input type="radio" name="limited collison deductible" value="$500" id="limited collison deductible" />
$500</label>
<br/>
<label>
<input type="radio" name="limited collison deductible" value="$1,000" id="limited collison deductible" />
$1,000</label>
<br/>
<br/>
<strong>Comprehensive Deductible (optional)</strong><br/>
<label>
<input type="radio" name="comprehensive deductible" value="none" id="comprehensive deductible" />
None</label>
<br/>
<label>
<input type="radio" name="comprehensive deductible" value="$300" id="comprehensive deductible" />
$300</label>
<br/>
<label>
<input type="radio" name="comprehensive deductible" value="$500" id="comprehensive deductible" />
$500</label>
<br/>
<label>
<input type="radio" name="comprehensive deductible" value="$1,000" id="comprehensive deductible" />
$1,000</label>
<br/>
<br/>
<strong>Substitute Transportation (optional)</strong><br/>
<label>
<input type="radio" name="substitute transportation" value="none" id="substitute transportation" />
None</label>
<br/>
<label>
<input type="radio" name="substitute transportation" value="$15/$450" id="substitute transportation" />
$15/$450</label>
<br/>
<label>
<input type="radio" name="substitute transportation" value="$30/$900" id="substitute transportation" />
$30/$900</label>
<br/>
<label>
<input type="radio" name="substitute transportation" value="$45/$1350" id="substitute transportation" />
$45/$1350</label>
<br/>
<label>
<input type="radio" name="substitute transportation" value="$100/$3000" id="substitute transportation" />
$100/$3000</label>
<br/>
<br/>
<strong>Towing and Labor (optional)</strong><br/>
<label>
<input type="radio" name="towing and labor" value="none" id="towing and labor" />
None</label>
<br/>
<label>
<input type="radio" name="towing and labor" value="$50" id="towing and labor" />
$50</label>
<br/>
<label>
<input type="radio" name="towing and labor" value="$100" id="towing and labor" />
$100</label>
<br/>
<br/>
<strong>Underinsured Motorist</strong>*<br/>
<label>
<input type="radio" name="underinsured motorist" value="$20,000/$40,000" id="underinsured motorist" />
$20,000/$40,000</label>
<br/>
<label>
<input type="radio" name="underinsured motorist" value="$50,000/$100,000" id="underinsured motorist" />
$50,000/$100,000</label>
<br/>
<label>
<input type="radio" name="underinsured motorist" value="$100,000/$300,000" id="underinsured motorist" />
$100,000/$300,000</label>
<br/>
<label>
<input type="radio" name="underinsured motorist" value="$250,000/$500,000" id="underinsured motorist" />
$250,000/$500,000</label>
<br/>
<br/>
<br/>
<h3>Please check any options that your vehicle is equiped with</h3>
<input type="checkbox" name="alarm" value="Yes" id="alarm" />
Alarm
</label>
<br/>
<label>
<input type="checkbox" name="airbags" value="Yes" id="airbags" />
Airbags</label>
<br/>
<label>
<input type="checkbox" name="guidepoint" value="Yes" id="guidepoint" />
GuidePoint</label>
<br/>
<label>
<input type="checkbox" name="lojack" value="Yes" id="lojack" />
LoJack</label>
<br/>
<label>
<input type="checkbox" name="onstar" value="Yes" id="onstar" />
OnStar</label>
<br/>
<br/>
<label>Questions/Comments<br/>
<textarea name="auto remarks" id="auto remarks" value="<?php echo $auto_remarks; ?>" cols="45" rows="5"></textarea>
</label>
<br/>
<br/>
</div> </div> <div id="home"> <div id="form-bottom-left"><br/>
<h2>Residence</h2>
<h3>Type of Insurance*</h3>
<label>
<input type="radio" name="type of insurance" value="Homeowners" id="type of insurance" />
Homeowners</label>
<br/>
<label>
<input type="radio" name="type of insurance" value="Condo" id="type of insurance" />
Condo</label>
<br/>
<label>
<input type="radio" name="type of insurance" value="Renters" id="type of insurance" />
Renters</label>
<br/>
<br/>
<label>
Social Security # (optional) <div id="disclaimer">
<li>Disclaimer
<ul>
<li>To accurately quote your auto insurance a social security number is necessary. Insurance companies reserve the right to reject your policy due to bad credit.</li>
</ul>
</li>
<br/>
</div>
<input name="ssn" type="password" class="text-field-home-narrow" id="ssn" value="<?php echo $ssn; ?>" />
</label>
<br/>
<label>How many units are in the building?*<br/>
<input name="number of units" type="text" class="text-field-home-narrow" id="number of units" value="<?php echo $number_of_units; ?>" />
</label>
<br/>
<label>Square footage?*<br/>
<input name="square footage" type="text" class="text-field-home-narrow" id="square footage" value="<?php echo $square_footage; ?>" />
</label>
<br/>
<label>Year built?*<br/>
<input name="year built" type="text" class="text-field-home-narrow" id="year built" value="<?php echo $year_built; ?>" />
</label>
<br/>
</div> <div id="form-bottom-bottom"><br/>
<label>Please list any pets and their breed:<br/>
<input name="pets" type="text" class="text-field-home" id="pets" value="<?php echo $pets; ?>" />
</label>
<br/>
<label>Please list any update(s) to property including year of update: <br/>
( e.g. electric, roof, plumbing, heating)<br/>
<input name="updates" type="text" class="text-field-home" id="updates" value="<?php echo $updates; ?>" />
</label>
<br/>
<label>Current insurance company?*<br/>
<input name="current insurance company" type="text" class="text-field-home" id="current insurance company" value="<?php echo $current_insurance_company; ?>" />
</label>
<br/>
<label>If policy was cancelled, why?<br/>
<input name="why was policy cancelled" type="text" class="text-field-home" id="why was policy cancelled" value="<?php echo $why_was_policy_cancelled; ?>" />
</label>
<br/>
<label>Please list any and all paid losses within the last three years<br/>
<input name="paid losses" type="text" class="text-field-home" id="paid losses" value="<?php echo $paid_losses; ?>" />
</label>
<br/>
<br/>
<label>
<input type="checkbox" name="amps" value="Yes" id="amps" />
I verify that the electrical system is circuit breakers and at least 100 amps*</label>
<br/>
<br/>
<strong><br/>
Does the owner live on the property?</strong>*
<p>
<label>
<input type="radio" name="does owner live on property" value="Yes" id="does owner live on property" />
Yes</label>
<br />
<label>
<input type="radio" name="does owner live on property" value="No" id="does owner live on property" />
No</label>
<br />
</p>
<strong>Is this a new or existing residence?</strong>*
<p>
<label>
<input type="radio" name="new or existing residence" value="New" id="new or existing residence" />
New</label>
<br />
<label>
<input type="radio" name="new or existing residence" value="Existing" id="new or existing residence" />
Existing</label>
<br />
</p>
<strong>What type of structure?</strong>*
<p>
<label>
<input type="radio" name="type of structure" value="Wood" id="type of structure" />
Wood</label>
<br />
<label>
<input type="radio" name="type of structure" value="Brick" id="type of structure" />
Brick</label>
<br />
</p>
<strong>What is your heating source?</strong>*
<p>
<label>
<input type="radio" name="heating source" value="Gas" id="heating source" />
Gas</label>
<br />
<label>
<input type="radio" name="heating source" value="Oil" id="heating source" />
Oil</label>
<br />
</p>
<strong>Has your coverage been cancelled in the last three years?</strong>*
<p>
<label>
<input type="radio" name="coverage cancelled" value="Yes" id="coverage cancelled" />
Yes</label>
<br />
<label>
<input type="radio" name="coverage cancelled" value="No" id="coverage cancelled" />
No</label>
<br />
</p>
<label>Questions/Comments<br/>
<textarea name="home remarks" id="home remarks" value="<?php echo $home_remarks; ?>" cols="45" rows="5"></textarea>
</label>
<br/>
<br/>
</div> </div> <div id="submit-button">
<input type="image" src="images/submit-button.jpg" name="submit" id="submit" value="Submit" /><br/><br/><p class="aterick">All fields marked with * are required</p>
</div> </div>
</form>

AnthonySterling · June 8, 2010, 1:51pm

You need to post the actual PHP code, not its output.

chris_upjohn · June 8, 2010, 1:51pm

This should help you out quite a bit

http://www.javascript-coder.com/javascript-form/javascript-reset-form.htm

samg914 · June 8, 2010, 1:31pm

This is the page: http://www.searchtransparencysem.com/projects/wedgwood/multi-insurance-quote-test.php

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