<% if (Request.Form("submit") <> "") then Dim date Dim description Dim facts Dim name_damaged Dim address_damaged Dim city_damaged Dim state_damaged Dim zip_damaged Dim home_phone_damaged Dim work_phone_damaged Dim cell_phone_damaged Dim email_damaged Dim time_damaged Dim age_damaged Dim employer_damaged dim name_defendant dim address_defendant dim city_defendant dim state_defendant dim zip_defendant dim defendant2 dim defendant3 dim item Dim bestTime Dim Conf, Mailer, Flds Set Conf = server.CreateObject("CDO.Configuration") Set Mailer = server.createobject("CDO.Message") Set Flds = Conf.Fields Flds.Item("http://schemas.microsoft.com/cdo/configuration/sendusing") = 2 Flds.Item("http://schemas.microsoft.com/cdo/configuration/smtpserver") = "192.168.1.180" Flds.Item("http://schemas.microsoft.com/cdo/configuration/smtpconnectiontimeout") = 60 Flds.Update Set Mailer.Configuration = Conf sFrom = "visitor@adamskiconti.com" Mailer.From = sFrom Mailer.To = "gaadamski@adamskiandconti.com; kconti@adamskiandconti.com; clhill@adamskiandconti.com" Mailer.Subject = "Free Case Evaluation Request" date = Request.Form("date") description = Request.Form("description") facts = Request.Form("facts") name_damaged = Request.Form("name_damaged") address_damaged = Request.Form("address_damaged") city_damaged = Request.Form("city_damaged") state_damaged = Request.Form("state_damaged") zip_injured = Request.Form("zip_injured") home_phone_damaged = Request.Form("home_phone_damaged") work_phone_damaged = Request.Form("work_phone_damaged") cell_phone_damaged = Request.Form("cell_phone_damaged") email_damaged = Request.Form("email_damaged") time_damaged = Request.Form("time_damaged") age_damaged = Request.Form("age_damaged") employer_damaged = Request.Form("employer_damaged") name_defendant = Request.Form("name_defendant") address_defendant = Request.Form("address_defendant") city_defendant = Request.Form("city_defendant") state_defendant = Request.Form("state_defendant") zip_defendant = Request.Form("zip_defendant") defendant2 = Request.Form("defendant2") defendant3 = Request.Form("defendant3") bestTime = Request.Form("time_damaged") If (bestTime = "") then bestTime = "No Preference" End if strBody = "

Case Description

" strBody = strBody & "Date of Incident: " &date strBody = strBody & "
Description: " &description strBody = strBody & "
Facts: " &facts strBody = strBody & "

Injured Contact Information

" strBody = strBody & "
Name: " &name_damaged strBody = strBody & "
Address: " &address_damaged strBody = strBody & "
City, State Zip: " &city_damaged &state_damaged &zip_damaged strBody = strBody & "
Home Phone: " &home_phone_damaged strBody = strBody & "
Work Phone: " &work_phone_damaged strBody = strBody & "
Cell Phone: " &cell_phone_damaged strBody = strBody & "

Defendant Contact Information

" strBody = strBody & "
Name: " &name_defendant strBody = strBody & "
Address: " &address_defendant strBody = strBody & "
City, State Zip: " &city_defendant &state_defendant &zip_defendant strBody = strBody & "
Defendant 2: " &defendant2 strBody = strBody & "
Defendant 3: " &defendant3 strBody = strBody & "




" Mailer.HTMLBody = strBody Mailer.Send set Mailer=Nothing set Conf=Nothing 'Response.Write("
"&strBody) Response.Redirect("thank_you.htm") end if %> Adamski & Conti

 


Practice AreasAbout the FirmCase EvaluationResourcesContact Us

 
For more information from Adamski & Conti, please fill out this form as completely as possible. We will contact you within 24 hours.

Case Information
Date of Incident: 

Describe Damage: 

Briefly State Facts: 

Primary Contact Information
Name: 

Address: 

City, State Zip: 

Home Phone: 

Work Phone: 

Cell Phone: 

Email: 

Best Time to Call: 

Age of Damaged Party:
Current Employer:
Target Defendant Contact Information
Name: 

Address: 

City, State Zip: 

Defendant 2: 

Defendant 3: