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__CONFIG_lead_generation_code__ <div id='crmWebToEntityForm' style='width:600px;margin:auto;'> <META HTTP-EQUIV ='content-type' CONTENT='text/html;charset=UTF-8'> <form action='https://crm.zoho.com/crm/WebToLeadForm' name=WebToLeads1219340000007025015 method='POST' onSubmit='javascript:document.charset="UTF-8"; return checkMandatory()' accept-charset='UTF-8'>  <input type='hidden' style='display:none;' name='xnQsjsdp' value='f3cd5fb4e97270b89185d3d18dcfedd81f95d083f11d4251a6f8aa5a236fd104'/> <input type='hidden' name='zc_gad' id='zc_gad' value=''/> <input type='hidden' style='display:none;' name='xmIwtLD' value='6493f835c4606d19f97406eb69f71a6081262f3dbaa85de7065ca3c59c1f1357'/> <input type='hidden' style='display:none;' name='actionType' value='TGVhZHM='/> <input type='hidden' style='display:none;' name='returnURL' value='https://mymedigapconsultant.com/thank-you' />  <input type='hidden' style='display:none;' id='ldeskuid' name='ldeskuid'></input> <input type='hidden' style='display:none;' id='LDTuvid' name='LDTuvid'></input>  <style> tr , td { padding:6px; border-spacing:0px; border-width:0px; } </style> <table style='width:600px;background-color:white;color:black'> <tr><td colspan='2' style='text-align:left;color:black;font-family:Arial;font-size:14px;'><strong>MMC Quote Form - Basic</strong></td></tr> <tr><td style='nowrap:nowrap;text-align:left;font-size:12px;font-family:Arial;width:200px;'>First Name<span style='color:red;'>*</span></td><td style='width:250px;' ><input type='text' style='width:250px;' maxlength='40' name='First Name' /></td></tr> <tr><td style='nowrap:nowrap;text-align:left;font-size:12px;font-family:Arial;width:200px;'>Last Name<span style='color:red;'>*</span></td><td style='width:250px;' ><input type='text' style='width:250px;' maxlength='80' name='Last Name' /></td></tr> <tr><td style='nowrap:nowrap;text-align:left;font-size:12px;font-family:Arial;width:200px;'>Date of Birth<span style='color:red;'>*</span></td><td style='width:250px;' ><input type='text' style='width:250px;' maxlength='20' name='LEADCF82' placeholder='mm/dd/yyyy' /></td></tr> <tr><td style='nowrap:nowrap;text-align:left;font-size:12px;font-family:Arial;width:200px;'>Email<span style='color:red;'>*</span></td><td style='width:250px;' ><input type='text' style='width:250px;' maxlength='100' name='Email' /></td></tr> <tr><td style='nowrap:nowrap;text-align:left;font-size:12px;font-family:Arial;width:200px;'>Phone<span style='color:red;'>*</span></td><td style='width:250px;' ><input type='text' style='width:250px;' maxlength='30' name='Phone' /></td></tr> <tr><td style='nowrap:nowrap;text-align:left;font-size:12px;font-family:Arial;width:200px;'>Zip Code<span style='color:red;'>*</span></td><td style='width:250px;' ><input type='text' style='width:250px;' maxlength='30' name='Zip Code' /></td></tr> <tr><td colspan='2' style='text-align:center; padding-top:15px;'> <input style='font-size:12px;color:#131307' type='submit' value='Submit' /> </td> </tr> </table> <script> var mndFileds=new Array('First Name','Last Name','Email','LEADCF82','Phone','Zip Code'); var fldLangVal=new Array('First Name','Last Name','Email','Date of Birth','Phone','Zip Code'); var name=''; var email=''; function checkMandatory() { for(i=0;i<mndFileds.length;i++) { var fieldObj=document.forms['WebToLeads1219340000007025015'][mndFileds[i]]; if(fieldObj) { if (((fieldObj.value).replace(/^s+|s+$/g, '')).length==0) { if(fieldObj.type =='file') { alert('Please select a file to upload.'); fieldObj.focus(); return false; } alert(fldLangVal[i] +' cannot be empty.'); fieldObj.focus(); return false; } else if(fieldObj.nodeName=='SELECT') { if(fieldObj.options[fieldObj.selectedIndex].value=='-None-') { alert(fldLangVal[i] +' cannot be none.'); fieldObj.focus(); return false; } } else if(fieldObj.type =='checkbox'){ if(fieldObj.checked == false){ alert('Please accept '+fldLangVal[i]); fieldObj.focus(); return false; } } try { if(fieldObj.name == 'Last Name') { name = fieldObj.value; } } catch (e) {} } } trackVisitor(); } </script><script type='text/javascript' id='VisitorTracking'>var $zoho= $zoho || {salesiq:{values:{},ready:function(){$zoho.salesiq.floatbutton.visible('hide');}}};var d=document;s=d.createElement('script');s.type='text/javascript';s.defer=true;s.src='https://salesiq.zoho.com/williamsinsurancegroup/float.ls?embedname=williamsinsurancegroup';t=d.getElementsByTagName('script')[0];t.parentNode.insertBefore(s,t);function trackVisitor(){try{if($zoho){var LDTuvidObj = document.forms['WebToLeads1219340000007025015']['LDTuvid'];if(LDTuvidObj){LDTuvidObj.value = $zoho.salesiq.visitor.uniqueid();}var firstnameObj = document.forms['WebToLeads1219340000007025015']['First Name'];if(firstnameObj){name = firstnameObj.value +' '+name;}$zoho.salesiq.visitor.name(name);var emailObj = document.forms['WebToLeads1219340000007025015']['Email'];if(emailObj){email = emailObj.value;$zoho.salesiq.visitor.email(email);}}} catch(e){}}</script> </form> </div>__CONFIG_lead_generation_code__

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