<% DIM strPage, strURL strPage = request("page") strURL = Request.ServerVariables("SCRIPT_NAME") %> Law Offices of Robert B. Williams
Workers' Compensation and Social Security Disability Specialist
Law Offices of Robert B. Williams
HOME | PROFESSIONAL SERVICES | SETTLEMENTS | LINKS | CONTACT US | HABLAMOS ESPAÑOL
 
CONTACT INFORMATION
<% Select Case strPage '--------------------------------------------------------------------------------------------------- ' Case Mailer Failed '--------------------------------------------------------------------------------------------------- Case "Failed" %> <% '--------------------------------------------------------------------------------------------------- ' Case Try to send the mail '--------------------------------------------------------------------------------------------------- Case "SendMail" DIM sHTML sHTML = "Information sent from www.ilworkerscomp.com
" sHTML = sHTML & "do not hit reply it will not work ... use data below to contact customer

" sHTML = sHTML & "Date sent: "&Request.Form("date")&"

" sHTML = sHTML & "Client Information:
"&Request.Form("Name")&"
" sHTML = sHTML & Request.Form("Address")&"
" sHTML = sHTML & Request.Form("City")&", "&Request.Form("MyState")&" "&Request.Form("Zip")&"

" sHTML = sHTML & "D.O.B.: "&Request.Form("bmonth")&"/"&Request.Form("bday")&"/"&Request.Form("byear")&"

" sHTML = sHTML & "Phone: ("&Request.Form("AreaCode")&")"&Request.Form("Phone")&"
" sHTML = sHTML & "Cell Phone: ("&Request.Form("CellAreaCode")&")"&Request.Form("CellPhone")&"

" sHTML = sHTML & "Email: "&Request.Form("EmailAddress")&"

" sHTML = sHTML & "Currently working: "&Request.Form("radioWorking")&"
" sHTML = sHTML & "Date of last employment: "&Request.Form("emonth")&"/"&Request.Form("eday")&"/"&Request.Form("eyear")&"
" sHTML = sHTML & "Position at old job: "&Request.Form("oldJob")&"
" sHTML = sHTML & "Date became disabled: "&Request.Form("dmonth")&"/"&Request.Form("dday")&"/"&Request.Form("dyear")&"
" sHTML = sHTML & "Has applied for SS Diablility: "&Request.Form("radioApplied")&"
" If Request.Form("radioApplied") = "yes" Then sHTML = sHTML & "Date has applied: "&Request.Form("SSmonth")&"/"&Request.Form("SSday")&"/"&Request.Form("SSyear")&"
" End If sHTML = sHTML & "What stage is the claim: "&Request.Form("stage")&"
" sHTML = sHTML & "Currently seeing a doctor: "&Request.Form("radioDoctor")&"

" sHTML = sHTML & "other information: "&Request.Form("moreInfo")&"
" sHTML = sHTML & "
" 'Response.Write sHTML 'Response.End call SendMail("info@ilworkerscomp.com", "info@ilworkerscomp.com", "", "abginc@aol.com", "||| website contact form |||", sHTML, true, false) ' ENABLE TO TEST ' call SendMail("info@ilworkerscomp.com", "marekk@americaneagle.com", "", "", "||| website contact form |||", sHTML, true, false) ' DIM objMail ' Set objMail = Server.CreateObject("CDO.Message") ' with objMail ' .From = "info@ilworkerscomp.com" ' .To = "info@ilworkerscomp.com" '.To = "abginc@aol.com" ' .Bcc = "abginc@aol.com" ' .Subject = "||| website contact form |||" ' .HTMLBody = sHTML ' .Send() ' End With ' Set objMail = Nothing Response.Redirect(strURL&"?page=ThankYou") '-------------------------------------------------------- '--------------------------------------------------------------------------------------------------- ' Case THANK YOU! '--------------------------------------------------------------------------------------------------- Case "ThankYou" %>

 

 


Thank You for contacting us... we'll reply soon!

Click here to go back to the home page.

 

 

<% '--------------------------------------------------------------------------------------------------- ' Case ELSE '--------------------------------------------------------------------------------------------------- Case else %>


LAW OFFICE OF ROBERT B. WILLIAMS

33 North LaSalle Street
Suite 2119
Chicago, Illinois 60602

312.782.9400
312.444.9400 fax

   info@ilworkerscomp.com
   rbw@ilworkerscomp.com

   Location Map

 

Please complete the form below and we will contact you as soon as possible...

Name: *
Date of Birth:  
Address:
City:
State: Zip:
Area Code &
Phone Number:		 - *
Area Code &
Cell Phone#:		 -
Email Address: *
Are You Currently Working?
YES NO
Date of latest employment:  
Your job position at above date:
Date did you become disabled?  
Have you already applied for
Social Security Disability?
YES NO
If Yes, when?  
At what stage is you claim?
Are you currently under the
care of a doctor or physician?
YES NO
other pertinate information
regarding your disability?
    
<% End Select %>

 
© Law Offices of Robert B. Williams