<?php
error_reporting( error_reporting() & ~E_NOTICE );
if(trim(strtolower($_SERVER['REQUEST_METHOD']))=="post")
{
	$sender = "Spetner Associates Contact Mailer <noreply@spetner.com>";
	$receivers = array("\"Laurie Close\" <lclose@spetner.com>", "\"Brandi Dunn\" <bdunn@spetner.com>");
	//$receivers = array("\"Plymouth J Cliffords\" <plymouthjcliffords@gmail.com>", "\"Aaron J Spetner\" <aaron@spetner.com>");
	
	$subject = "Spetner.com Contact";
	
	$email_body = "First Name: ".$_POST['ifirstname']."\r\n";
	$email_body.= "Last Name: ".$_POST['ilastname']."\r\n";
	$email_body.= "Title: ".$_POST['ititle']."\r\n";
	$email_body.= "Company: ".$_POST['icompany']."\r\n";
	$email_body.= "Address: ".$_POST['iaddress']."\r\n";
	$email_body.= "City: ".$_POST['icity']."\r\n";
	$email_body.= "State: ".$_POST['istate']."\r\n";
	$email_body.= "Zip: ".$_POST['izip']."\r\n";
	$email_body.= "Country: ".$_POST['icountry']."\r\n";
	$email_body.= "Phone: ".$_POST['iphone']."\r\n";
	$email_body.= "Fax: ".$_POST['ifax']."\r\n";
	$email_body.= "Email: ".$_POST['iemail']."\r\n";
	$email_body.= "\r\n";
	$email_body.= "I would like more information about the following:\r\n";
	$email_body.= "Employee Benefits: " . ($_POST['ickEmpBenefits'] == "SELECTED" ? "Yes" : "No") . "\r\n";
	$email_body.= "Individual Benefits: " . ($_POST['ickIndBenefits'] == "SELECTED" ? "Yes" : "No") . "\r\n";
	$email_body.= "Human Resource Assisted Programs: " . ($_POST['ickHumanResource'] == "SELECTED" ? "Yes" : "No") . "\r\n";
	$email_body.= "Assisted Online Enrollment: " . ($_POST['ickckAOE'] == "SELECTED" ? "Yes" : "No") . "\r\n";
	$email_body.= "Term Life Insurance: " . ($_POST['ickTermLife'] == "SELECTED" ? "Yes" : "No") . "\r\n";
	$email_body.= "Estate Planning: " . ($_POST['ickEstate'] == "SELECTED" ? "Yes" : "No") . "\r\n";
	if($_POST["iradiobutton"] == "yes")
	{
		$email_body.= "\r\nPlease send me a brochure.\r\n";
	}
		
	$email_body .= "\r\n\r\n--\r\nSpetner Associates\r\n8630 Delmar Blvd\r\nSuite 100\r\nSaint Louis, MO 63124\r\n\r\n+1-314-442-0000\r\n+1-800-737-4535\r\nFax: +1-314-442-0099\r\n";
	
	$extra = "From: $sender\r\n" . "Reply-To: ".$_POST['iemail']."\r\n" . "X-Mailer: PHP/" . phpversion();
	$extra2 = "From: $sender\r\n" . "X-Mailer: PHP/" . phpversion();

	
	
	mail($_POST['iemail'], "Thank you for contacting Spetner Associates", "Thank you for contacting Spetner Associates. Someone will respond to you shortly.\r\n\r\nA copy of your request is below:\r\n\r\n".$email_body, $extra2, "-fnoreply@spetner.com");
	
	
	if(mail(implode($receivers, ", "), "$subject - ".$_POST['ifirstname'] . " " . $_POST['ilastname'], $email_body, $extra, "-fnoreply@spetner.com"))
	{
		echo "1";
	}
	else
	{
		echo "0";
	}
	
	die();
}
?>
<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN">

<html>
<head>
<title>Spetner Associates, Inc.</title>
<meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1">
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				$('#dvLoading').hide();
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<link href="css/spetner.css" rel="stylesheet" type="text/css">
<!-- InstanceBeginEditable name="head" --><!-- InstanceEndEditable -->
</head>

<body bgcolor="#666666" onLoad="MM_preloadImages('images/loginbtn2.gif','images/homebtn2.gif','images/prodservbtn2.gif','images/indresbtn2.gif','images/newsbtn2.gif','images/aboutbtn2.gif','images/contactbtn2.gif')">
<table width="720" border="0" align="center" cellpadding="0" cellspacing="0">
  <tr>
    <td bgcolor="#FFFFFF">
      <table width="100%" border="0" cellspacing="0" cellpadding="0">
        <tr>
          <td width="50%" valign="top"><img src="images/headerleft.gif" width="367" height="88"></td>
          <td valign="top"><!-- InstanceBeginEditable name="EditRegion4" --><img src="images/contacthdr.gif" width="353" height="88"><!-- InstanceEndEditable --></td>
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  </tr>
  <tr>
    <td bgcolor="#FFFFFF"><!-- InstanceBeginEditable name="EditRegion3" -->
      <table width="100%" border="0" cellspacing="0" cellpadding="5">
        <tr>
          <td valign="top"><p class="bodyheader">CONTACT US</p>
            <table width="100%" border="0" cellspacing="10" cellpadding="0">
              <tr> 
                <td width="31%" valign="top" itemscope itemtype="http://schema.org/Organization">
<p itemprop="name"><span class="bodyheader"><strong>Spetner Associates</strong></span></p>
<p itemscope itemtype="http://schema.org/PostalAddress">
                    <span itemprop="streetAddress">8630 Delmar Blvd<br>
                    Suite 100</span><br>
                  <span itemprop="addressLocality">St. Louis</span>, <span itemprop="addressRegion">MO</span> <span itemprop="postalCode">63124</span></p>
                  <table width="200" border="0" cellspacing="0" cellpadding="0">
                    <tr>
                      <td width="49" valign="top">Phone: </td>
                      <td width="151"><span itemprop="telephone">314-442-0000</span> or <br>
800-737-4535</td>
                    </tr>
                  </table>
                  <p>Fax: 314-442-0099</p>
                  <p>E-mail: <a href="mailto:info@spetner.com">info@spetner.com</a></p>
                  <p><a href="http://www.mapquest.com/maps/print.adp?mapdata=gq%2bXeik9PDGMUngTDeDRJI5M893LKxTxX9u3RSz394wEAvBu%2fAnSLwBPtNd8iKScBlU2cTt1IiywtQF3uALeX7Td4wmekWv3W5J%2fevWFa8B7%2b%2fs%2fFKYqv5ONxPLQOodQ96dx7HB7EJoRRlR7Dg07EZzqjtn0OqfjTv%2b6OpBjM2%2bapfqW3fKNat9dYnNlrS6jkzpe2DCh%2fR9hPo6n5FwUWlgjvR2PRB6VtzoZbjIpqj7MKzfo%2fMymRoLPx5YRNSw%2fQVsqEvoYfFisC4z2INONb%2bmL4lqJstEBhFyLrAVdvCaKGMThgkAxOD5yz4fcBtjz5lo%2fLpRea%2b0%3d" target="_blank">For 
                    a printable map and directions click here</a><br>
                  </p>
                  <p><img src="images/building1.jpg" width="200" height="138"></p></td>
				<td width="1" bgcolor="#666666"><img src="images/blank.gif" width="1" height="1"></td>
                <td width="69%" valign="top">
				<p class="bodyheader">Information Request</p>
				<div id="dvLoading" style="display: none;text-align: center">
					Submitting... Please wait.
					<br/>
					<img alt="" src="/images/ajax-loader.gif" />
				</div>
				<div id="dvSuccess" style="display:none;text-align: center;">
					<br/><br/><br/>
					<b>Thank you. Your request has been successfully submitted.</b>
					<br/>
					A representative will contact you shortly via the contact information you provided.
				</div>
				<form action="" method="post" name="contact" class="bodyheader4" id="frmContact">
                  <table width="350" border="0" cellpadding="5" cellspacing="0" class="bodyheader4">
                    <tr valign="top">
                      <td width="50%" class="required">First Name:</td>
                      <td width="50%"><input type="text" size=20 maxlength=50 name="firstname" data-title="First Name">
                      </td>
                    </tr>
                    <tr valign="top">
                      <td width="50%" class="required">Last Name:</td>
                      <td width="50%"><input type="text" size=20 maxlength=50 name="lastname" data-title="Last Name">
                      </td>
                    </tr>
                    <tr valign="top">
                      <td width="50%">Title:</td>
                      <td width="50%"><input type="text" name="title" data-title="Title">
                      </td>
                    </tr>
                    <tr valign="top">
                      <td width="50%">Company:</td>
                      <td width="50%"><input type="text" name="company" data-title="Company">
                      </td>
                    </tr>
                    <tr valign="top">
                      <td width="50%" class="required">Address:</td>
                      <td width="50%"><input type="text" name="address" data-title="Address">
                      </td>
                    </tr>
                    <tr valign="top">
                      <td width="50%" class="required">City:</td>
                      <td width="50%"><input type="text" size=20 maxlength=50 name="city" data-title="City"></td>
                    </tr>
                    <tr valign="top">
                      <td width="50%" class="required">State/Zip:</td>
                      <td width="50%">
						<select name="state" data-title="State">
							<option value="">-- Choose One --</option>
							<option value="AL">Alabama</option>
							<option value="AK">Alaska</option>
							<option value="AZ">Arizona</option>
							<option value="AR">Arkansas</option>
							<option value="CA">California</option>
							<option value="CO">Colorado</option>
							<option value="CT">Connecticut</option>
							<option value="DE">Delaware</option>
							<option value="DC">District of Columbia</option>
							<option value="FL">Florida</option>
							<option value="GA">Georgia</option>
							<option value="HI">Hawaii</option>
							<option value="ID">Idaho</option>
							<option value="IL">Illinois</option>
							<option value="IN">Indiana</option>
							<option value="IA">Iowa</option>
							<option value="KS">Kansas</option>
							<option value="KY">Kentucky</option>
							<option value="LA">Louisiana</option>
							<option value="ME">Maine</option>
							<option value="MD">Maryland</option>
							<option value="MA">Massachusetts</option>
							<option value="MI">Michigan</option>
							<option value="MN">Minnesota</option>
							<option value="MS">Mississippi</option>
							<option value="MO">Missouri</option>
							<option value="MT">Montana</option>
							<option value="NE">Nebraska</option>
							<option value="NV">Nevada</option>
							<option value="NH">New Hampshire</option>
							<option value="NJ">New Jersey</option>
							<option value="NM">New Mexico</option>
							<option value="NY">New York</option>
							<option value="NC">North Carolina</option>
							<option value="ND">North Dakota</option>
							<option value="OH">Ohio</option>
							<option value="OK">Oklahoma</option>
							<option value="OR">Oregon</option>
							<option value="PA">Pennsylvania</option>
							<option value="RI">Rhode Island</option>
							<option value="SC">South Carolina</option>
							<option value="SD">South Dakota</option>
							<option value="TN">Tennessee</option>
							<option value="TX">Texas</option>
							<option value="UT">Utah</option>
							<option value="VT">Vermont</option>
							<option value="VA">Virginia</option>
							<option value="WA">Washington</option>
							<option value="WV">West Virginia</option>
							<option value="WI">Wisconsin</option>
							<option value="WY">Wyoming</option>
						</select>
						&nbsp;
						<input type="text" size=10 maxlength=10 name="zip" data-title="Zip">
                      </td>
                    </tr>
                    <tr valign="top">
                      <td width="50%" height="40">Country</td>
                      <td width="50%">
						<select name="country" data-title="Country">
							<option value="Afghanistan">Afghanistan</option>
							<option value="Åland Islands">Åland Islands</option>
							<option value="Albania">Albania</option>
							<option value="Algeria">Algeria</option>
							<option value="American Samoa">American Samoa</option>
							<option value="Andorra">Andorra</option>
							<option value="Angola">Angola</option>
							<option value="Anguilla">Anguilla</option>
							<option value="Antarctica">Antarctica</option>
							<option value="Antigua and Barbuda">Antigua and Barbuda</option>
							<option value="Argentina">Argentina</option>
							<option value="Armenia">Armenia</option>
							<option value="Aruba">Aruba</option>
							<option value="Australia">Australia</option>
							<option value="Austria">Austria</option>
							<option value="Azerbaijan">Azerbaijan</option>
							<option value="Bahamas">Bahamas</option>
							<option value="Bahrain">Bahrain</option>
							<option value="Bangladesh">Bangladesh</option>
							<option value="Barbados">Barbados</option>
							<option value="Belarus">Belarus</option>
							<option value="Belgium">Belgium</option>
							<option value="Belize">Belize</option>
							<option value="Benin">Benin</option>
							<option value="Bermuda">Bermuda</option>
							<option value="Bhutan">Bhutan</option>
							<option value="Bolivia">Bolivia</option>
							<option value="Bosnia and Herzegovina">Bosnia and Herzegovina</option>
							<option value="Botswana">Botswana</option>
							<option value="Bouvet Island">Bouvet Island</option>
							<option value="Brazil">Brazil</option>
							<option value="British Indian Ocean Territory">British Indian Ocean Territory</option>
							<option value="Brunei Darussalam">Brunei Darussalam</option>
							<option value="Bulgaria">Bulgaria</option>
							<option value="Burkina Faso">Burkina Faso</option>
							<option value="Burundi">Burundi</option>
							<option value="Cambodia">Cambodia</option>
							<option value="Cameroon">Cameroon</option>
							<option value="Canada">Canada</option>
							<option value="Cape Verde">Cape Verde</option>
							<option value="Cayman Islands">Cayman Islands</option>
							<option value="Central African Republic">Central African Republic</option>
							<option value="Chad">Chad</option>
							<option value="Chile">Chile</option>
							<option value="China">China</option>
							<option value="Christmas Island">Christmas Island</option>
							<option value="Cocos (Keeling) Islands">Cocos (Keeling) Islands</option>
							<option value="Colombia">Colombia</option>
							<option value="Comoros">Comoros</option>
							<option value="Congo">Congo</option>
							<option value="Congo, The Democratic Republic of The">Congo, The Democratic Republic of The</option>
							<option value="Cook Islands">Cook Islands</option>
							<option value="Costa Rica">Costa Rica</option>
							<option value="Cote D'ivoire">Cote D'ivoire</option>
							<option value="Croatia">Croatia</option>
							<option value="Cuba">Cuba</option>
							<option value="Cyprus">Cyprus</option>
							<option value="Czech Republic">Czech Republic</option>
							<option value="Denmark">Denmark</option>
							<option value="Djibouti">Djibouti</option>
							<option value="Dominica">Dominica</option>
							<option value="Dominican Republic">Dominican Republic</option>
							<option value="Ecuador">Ecuador</option>
							<option value="Egypt">Egypt</option>
							<option value="El Salvador">El Salvador</option>
							<option value="Equatorial Guinea">Equatorial Guinea</option>
							<option value="Eritrea">Eritrea</option>
							<option value="Estonia">Estonia</option>
							<option value="Ethiopia">Ethiopia</option>
							<option value="Falkland Islands (Malvinas)">Falkland Islands (Malvinas)</option>
							<option value="Faroe Islands">Faroe Islands</option>
							<option value="Fiji">Fiji</option>
							<option value="Finland">Finland</option>
							<option value="France">France</option>
							<option value="French Guiana">French Guiana</option>
							<option value="French Polynesia">French Polynesia</option>
							<option value="French Southern Territories">French Southern Territories</option>
							<option value="Gabon">Gabon</option>
							<option value="Gambia">Gambia</option>
							<option value="Georgia">Georgia</option>
							<option value="Germany">Germany</option>
							<option value="Ghana">Ghana</option>
							<option value="Gibraltar">Gibraltar</option>
							<option value="Greece">Greece</option>
							<option value="Greenland">Greenland</option>
							<option value="Grenada">Grenada</option>
							<option value="Guadeloupe">Guadeloupe</option>
							<option value="Guam">Guam</option>
							<option value="Guatemala">Guatemala</option>
							<option value="Guernsey">Guernsey</option>
							<option value="Guinea">Guinea</option>
							<option value="Guinea-bissau">Guinea-bissau</option>
							<option value="Guyana">Guyana</option>
							<option value="Haiti">Haiti</option>
							<option value="Heard Island and Mcdonald Islands">Heard Island and Mcdonald Islands</option>
							<option value="Holy See (Vatican City State)">Holy See (Vatican City State)</option>
							<option value="Honduras">Honduras</option>
							<option value="Hong Kong">Hong Kong</option>
							<option value="Hungary">Hungary</option>
							<option value="Iceland">Iceland</option>
							<option value="India">India</option>
							<option value="Indonesia">Indonesia</option>
							<option value="Iran, Islamic Republic of">Iran, Islamic Republic of</option>
							<option value="Iraq">Iraq</option>
							<option value="Ireland">Ireland</option>
							<option value="Isle of Man">Isle of Man</option>
							<option value="Israel">Israel</option>
							<option value="Italy">Italy</option>
							<option value="Jamaica">Jamaica</option>
							<option value="Japan">Japan</option>
							<option value="Jersey">Jersey</option>
							<option value="Jordan">Jordan</option>
							<option value="Kazakhstan">Kazakhstan</option>
							<option value="Kenya">Kenya</option>
							<option value="Kiribati">Kiribati</option>
							<option value="Korea, Democratic People's Republic of">Korea, Democratic People's Republic of</option>
							<option value="Korea, Republic of">Korea, Republic of</option>
							<option value="Kuwait">Kuwait</option>
							<option value="Kyrgyzstan">Kyrgyzstan</option>
							<option value="Lao People's Democratic Republic">Lao People's Democratic Republic</option>
							<option value="Latvia">Latvia</option>
							<option value="Lebanon">Lebanon</option>
							<option value="Lesotho">Lesotho</option>
							<option value="Liberia">Liberia</option>
							<option value="Libyan Arab Jamahiriya">Libyan Arab Jamahiriya</option>
							<option value="Liechtenstein">Liechtenstein</option>
							<option value="Lithuania">Lithuania</option>
							<option value="Luxembourg">Luxembourg</option>
							<option value="Macao">Macao</option>
							<option value="Macedonia, The Former Yugoslav Republic of">Macedonia, The Former Yugoslav Republic of</option>
							<option value="Madagascar">Madagascar</option>
							<option value="Malawi">Malawi</option>
							<option value="Malaysia">Malaysia</option>
							<option value="Maldives">Maldives</option>
							<option value="Mali">Mali</option>
							<option value="Malta">Malta</option>
							<option value="Marshall Islands">Marshall Islands</option>
							<option value="Martinique">Martinique</option>
							<option value="Mauritania">Mauritania</option>
							<option value="Mauritius">Mauritius</option>
							<option value="Mayotte">Mayotte</option>
							<option value="Mexico">Mexico</option>
							<option value="Micronesia, Federated States of">Micronesia, Federated States of</option>
							<option value="Moldova, Republic of">Moldova, Republic of</option>
							<option value="Monaco">Monaco</option>
							<option value="Mongolia">Mongolia</option>
							<option value="Montenegro">Montenegro</option>
							<option value="Montserrat">Montserrat</option>
							<option value="Morocco">Morocco</option>
							<option value="Mozambique">Mozambique</option>
							<option value="Myanmar">Myanmar</option>
							<option value="Namibia">Namibia</option>
							<option value="Nauru">Nauru</option>
							<option value="Nepal">Nepal</option>
							<option value="Netherlands">Netherlands</option>
							<option value="Netherlands Antilles">Netherlands Antilles</option>
							<option value="New Caledonia">New Caledonia</option>
							<option value="New Zealand">New Zealand</option>
							<option value="Nicaragua">Nicaragua</option>
							<option value="Niger">Niger</option>
							<option value="Nigeria">Nigeria</option>
							<option value="Niue">Niue</option>
							<option value="Norfolk Island">Norfolk Island</option>
							<option value="Northern Mariana Islands">Northern Mariana Islands</option>
							<option value="Norway">Norway</option>
							<option value="Oman">Oman</option>
							<option value="Pakistan">Pakistan</option>
							<option value="Palau">Palau</option>
							<option value="Panama">Panama</option>
							<option value="Papua New Guinea">Papua New Guinea</option>
							<option value="Paraguay">Paraguay</option>
							<option value="Peru">Peru</option>
							<option value="Philippines">Philippines</option>
							<option value="Pitcairn">Pitcairn</option>
							<option value="Poland">Poland</option>
							<option value="Portugal">Portugal</option>
							<option value="Puerto Rico">Puerto Rico</option>
							<option value="Qatar">Qatar</option>
							<option value="Reunion">Reunion</option>
							<option value="Romania">Romania</option>
							<option value="Russian Federation">Russian Federation</option>
							<option value="Rwanda">Rwanda</option>
							<option value="Saint Helena">Saint Helena</option>
							<option value="Saint Kitts and Nevis">Saint Kitts and Nevis</option>
							<option value="Saint Lucia">Saint Lucia</option>
							<option value="Saint Pierre and Miquelon">Saint Pierre and Miquelon</option>
							<option value="Saint Vincent and The Grenadines">Saint Vincent and The Grenadines</option>
							<option value="Samoa">Samoa</option>
							<option value="San Marino">San Marino</option>
							<option value="Sao Tome and Principe">Sao Tome and Principe</option>
							<option value="Saudi Arabia">Saudi Arabia</option>
							<option value="Senegal">Senegal</option>
							<option value="Serbia">Serbia</option>
							<option value="Seychelles">Seychelles</option>
							<option value="Sierra Leone">Sierra Leone</option>
							<option value="Singapore">Singapore</option>
							<option value="Slovakia">Slovakia</option>
							<option value="Slovenia">Slovenia</option>
							<option value="Solomon Islands">Solomon Islands</option>
							<option value="Somalia">Somalia</option>
							<option value="South Africa">South Africa</option>
							<option value="South Georgia and The South Sandwich Islands">South Georgia and The South Sandwich Islands</option>
							<option value="Spain">Spain</option>
							<option value="Sri Lanka">Sri Lanka</option>
							<option value="Sudan">Sudan</option>
							<option value="Suriname">Suriname</option>
							<option value="Svalbard and Jan Mayen">Svalbard and Jan Mayen</option>
							<option value="Swaziland">Swaziland</option>
							<option value="Sweden">Sweden</option>
							<option value="Switzerland">Switzerland</option>
							<option value="Syrian Arab Republic">Syrian Arab Republic</option>
							<option value="Taiwan, Province of China">Taiwan, Province of China</option>
							<option value="Tajikistan">Tajikistan</option>
							<option value="Tanzania, United Republic of">Tanzania, United Republic of</option>
							<option value="Thailand">Thailand</option>
							<option value="Timor-leste">Timor-leste</option>
							<option value="Togo">Togo</option>
							<option value="Tokelau">Tokelau</option>
							<option value="Tonga">Tonga</option>
							<option value="Trinidad and Tobago">Trinidad and Tobago</option>
							<option value="Tunisia">Tunisia</option>
							<option value="Turkey">Turkey</option>
							<option value="Turkmenistan">Turkmenistan</option>
							<option value="Turks and Caicos Islands">Turks and Caicos Islands</option>
							<option value="Tuvalu">Tuvalu</option>
							<option value="Uganda">Uganda</option>
							<option value="Ukraine">Ukraine</option>
							<option value="United Arab Emirates">United Arab Emirates</option>
							<option value="United Kingdom">United Kingdom</option>
							<option value="United States" selected="selected">United States</option>
							<option value="United States Minor Outlying Islands">United States Minor Outlying Islands</option>
							<option value="Uruguay">Uruguay</option>
							<option value="Uzbekistan">Uzbekistan</option>
							<option value="Vanuatu">Vanuatu</option>
							<option value="Venezuela">Venezuela</option>
							<option value="Viet Nam">Viet Nam</option>
							<option value="Virgin Islands, British">Virgin Islands, British</option>
							<option value="Virgin Islands, U.S.">Virgin Islands, U.S.</option>
							<option value="Wallis and Futuna">Wallis and Futuna</option>
							<option value="Western Sahara">Western Sahara</option>
							<option value="Yemen">Yemen</option>
							<option value="Zambia">Zambia</option>
							<option value="Zimbabwe">Zimbabwe</option>
						</select>
                      </td>
                    </tr>
                    <tr valign="top">
                      <td width="50%">Telephone:</td>
                      <td width="50%"><input type="text" size="12" maxlength="20" name="phone" data-title="Telephone">
                      </td>
                    </tr>
                    <tr valign="top">
                      <td width="50%">Fax:</td>
                      <td width="50%"><input type="text" size="12" maxlength="20" name="fax" data-title="Fax">
                      </td>
                    </tr>
                    <tr valign="top">
                      <td width="50%" class="required">E-mail:</td>
                      <td width="50%"><input type="text" size=20 maxlength=50 name="email" data-title="Email">
                      </td>
                    </tr>
                  </table>
                  <span class="bodyheader4">Required Fields are in </span><span class="required">Green</span>.<br>
                  <p class="bodyheader4">I would like more information about
                    the following:</p>
                  <p class="bodyheader4">
					<label>
						<input type="checkbox" value="SELECTED" name="ckEmpBenefits">
						Employee Benefits
					</label>
					<br/>
					<label>
						<input type="checkbox" value="SELECTED" name="ckIndBenefits">
						Individual Benefits
					</label>
					<br/>
					<label>
						<input type="checkbox" value="SELECTED" name="ckHumanResource">
						Human Resource Assistance Programs
					</label>
					<br/>
					<label>
						<input type="checkbox" value="SELECTED" name="ckAOE">
						Assisted Online Enrollment
					</label>
					<br/>
					<label>
						<input type="checkbox" value="SELECTED" name="ckTermLife">
						Term Life Insurance
					</label>
					<br/>
					<label>
						<input type="checkbox" value="SELECTED" name="ckEstate">
						Estate Planning
					</label>
                  <p class="bodyheader4">Please send me a brochure
                      <input name="radiobutton" type="radio" value="yes" checked="checked"> yes <input type="radio" name="radiobutton" value="no"> no</p>
                  <p class="bodyheader2">
                    <input type="submit" name="Submit" value="Submit">
                  </p>
                </form></td>
              </tr>
            </table>
          </td>
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