is_error()) { //$template->set('display_formcheck_errors', '' . $fv->display_errors() . ''); $msg_changes_saved = "

Please fill in the neccessary details for the Quote Motor form!

"; } else { $contact_us_output = contact_us($contact_details); $msg_changes_saved = "

" . $contact_us_output . "

"; } } if (!$form_submitted) { $post_details = ($contact_post) ? $_REQUEST : $contact_details; } } function contact_us($quote_motor_details) { (string) $display_output = null; global $setts; ## email here include('mails/quote_motor.php'); $display_output = "Quote Motor Request Send Successfully!"; return $display_output; } ?>

Motor Quote Request

Please fill in the details below as accurate as possible. Our consultant will get back to you very shortly.

Insured's Name
Married/Single Married Single
Female/Male Female Male
NRIC No
DOB
Occupation
Driving Exp yrs
Any Claim Record for the Past 3 Years Yes No
Amount of Claim (SGD)
No Claim Discount %

From Which Insurer

Car Details

Reg No
Make/Model of Car

cc
Year of Manufacturer

Any Named Drivers

Relationship with Insured
Name
Married/Single Married Single
Female/Male Female Male
DOB
NRIC No
Occupation
Driving Exp yrs
Any Claim Record for the Past 3 Years Yes No
Amount of Claim (SGD)