<?php

if(isset($_POST['left']))
{
$name=$_POST['name'];
$email=$_POST['email'];
$company=$_POST['company'];
$address=$_POST['address'];
$city=$_POST['city'];
$state=$_POST['state'];
$zip=$_POST['zip'];
$phone=$_POST['phone'];
$practice=$_POST['practice'];
$physicians=$_POST['physicians'];
$billing=$_POST['billing'];
$about=$_POST['about'];
$comment=$_POST['comment'];


$to="contactus@claimxperts.com";

$subject="Claimxperts - $name";
$message="<html>
<head>

<title>User Details</title>
</head>
<body>
<table width='100%' cellpadding='2' cellspacing='4' border='0' style='border:1px dashed #009966;'>

<tr><td style='font-family: Arial, Helvetica, sans-serif; font-size:16px; font-weight:bold; padding-bottom:10px;'>The Contact Detail of user :</td></tr>

<tr><td style='font-family:Arial, Helvetica, sans-serif; font-size:13px;'><strong>Full Name</strong> :- $name</td></tr>

<tr><td style='font-family:Arial, Helvetica, sans-serif; font-size:13px;'><strong>Email Address</strong> :- $email</td></tr>

<tr><td style='font-family:Arial, Helvetica, sans-serif; font-size:13px;'><strong>Company Name</strong> :- $company</td></tr>

<tr><td style='font-family:Arial, Helvetica, sans-serif; font-size:13px;'><strong>Address</strong> :- $address</td></tr>

<tr><td style='font-family:Arial, Helvetica, sans-serif; font-size:13px;'><strong>City</strong> :- $city</td></tr>

<tr><td style='font-family:Arial, Helvetica, sans-serif; font-size:13px;'><strong>State</strong> :- $state</td></tr>

<tr><td style='font-family:Arial, Helvetica, sans-serif; font-size:13px;'><strong>Zip</strong> :- $zip</td></tr>

<tr><td style='font-family:Arial, Helvetica, sans-serif; font-size:13px;'><strong>Phone</strong> :- $phone</td></tr>

<tr><td style='font-family:Arial, Helvetica, sans-serif; font-size:13px;'><strong>Type of Practice</strong> :- $practice</td></tr>

<tr><td style='font-family:Arial, Helvetica, sans-serif; font-size:13px;'><strong>No of Physicians</strong> :- $physicians</td></tr>

<tr><td style='font-family:Arial, Helvetica, sans-serif; font-size:13px;'><strong>Average Monthly Billing Amount</strong> :- $billing</td></tr>

<tr><td style='font-family:Arial, Helvetica, sans-serif; font-size:13px;'><strong>How you hear about us?</strong> :- $about</td></tr>

<tr><td style='font-family:Arial, Helvetica, sans-serif; font-size:13px;'><strong>Comment</strong> :- $comment</td></tr>

</table>
</body>

</html>";



$from="mir@eleadmedia.com";
$headers = "From: Claimxperts  <$from>\n";
$headers .= "MIME-Version: 1.0\n";
$headers .= "Return-Path: \n";
$headers .= "Content-Type: text/html;\n";
$headers .= "X-Mailer: PHP/" . phpversion();
$sentmail=mail($to,$subject,$message,$headers);
header('location: thanks.php');

} 

?>

<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml">
<head>
<meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1" />
<title>Welcome To ClaimsXperts</title>
<link href="css.css" rel="stylesheet" type="text/css" />
<script src="js/contentslider.js" type="text/javascript"></script>
<script src="js/jquery.min.js" type="text/javascript"></script>
<script src="js/jquery.validate.js" type="text/javascript"></script>
<script src="js/custom.js" type="text/javascript"></script>
</head>

<body>
<div id="fotter-bg">

<div id="left-icon">
  <a href="contact-us.php"><img src="images/appointment.jpg" alt="" border="0" /></a>
<div class="line"></div>
<a href="http://facebook.com/" target="_blank"><img src="images/face.jpg" border="0" alt="" /></a> <a href="https://twitter.com/" target="_blank"><img src="images/twi.jpg" alt="" border="0" /></a>
</div>


<div id="right-icon">
  <a href="request-quote.php"><img src="images/quote.jpg" alt="" border="0" /></a>
<div class="line"></div>
<a href="download.pdf" target="_blank"><img src="images/download-pdf.jpg" alt="" border="0" /></a>
</div>


<div id="top-bg">
<!--Header-->
<div id="header">
<div class="logo"><a href="index.html"><img src="images/logo.png" alt="" border="0" /></a></div>
<div class="right"><a href="index.html">Home</a>   |   <a href="sitemap.html">Sitemap</a>   |   <a href="contact-us.php">Contact Us</a>  |  <a href="testimonials.html">Testimonials</a> 

<div class="call"> 773-829-7198</div>
</div>

<div id="menu">
<ul id="menu-drop">
<li><a href="index.html">Home</a></li>
<li><a href="about-us.html">About us</a></li>
<li><a href="why-us.html">Why us</a></li>
<li><a href="pricing.html">Pricing</a></li>
<li><a href="faq.html">Faq's</a></li>
<li><a href="process-flow.html">Process Flow</a></li>
<li><a href="#">Our Services</a>
<ul>

<li><a href="medical-billing-offering.html">Medical Billing Service Offerings</a></li>
<li><a href="medical-billing-services.html">Medical Billing Services</a></li>
<li><a href="medical-coding-process.html">Medical Coding Process</a></li>
<li><a href="other-services.html">Other Services</a></li>
</ul>
</li>
</ul>
</div>
<div class="clear"></div>
</div>
<!--Header Close-->

<!--Middle-->
<div id="middle">
<div id="new-latter">
<h2>Try this out</h2>
<h3>No-obligation Billing Trial Offer.</h3>
<p>Provide us your email or call us on our Contact no.</p>
<form action="mail1.php" id="getStart" name="getStart" method="post">
<input type="mail" name="email" class="input" required /> <input type="submit" name="" class="send-mail" value="submit" />
</form>
<div class="clear"></div>
<h4>Contact Number</h4>
<h5> 773-829-7198</h5>

</div>


<!--silder-->
<div id="slider1" class="sliderwrapper">
<div class="contentdiv" style="background:url(images/silder1.png) top no-repeat;"></div>
<div class="contentdiv" style="background:url(images/silder2.png) top no-repeat;"></div>
<div class="contentdiv" style="background:url(images/silder3.png) top no-repeat;"></div>
<div id="paginate-slider1" class="pagination" align="center"></div>

<script type="text/javascript">

featuredcontentslider.init({
	id: "slider1",  //id of main slider DIV
	contentsource: ["inline", ""],  //Valid values: ["inline", ""] or ["ajax", "path_to_file"]
	toc: "#increment",  //Valid values: "#increment", "markup", ["label1", "label2", etc]
	nextprev: ["", ""],  //labels for "prev" and "next" links. Set to "" to hide.
	revealtype: "click", //Behavior of pagination links to reveal the slides: "click" or "mouseover"
	enablefade: [true, 0.2],  //[true/false, fadedegree]
	autorotate: [true, 3000],  //[true/false, pausetime]
	onChange: function(previndex, curindex, contentdivs){  //event handler fired whenever script changes slide
		//previndex holds index of last slide viewed b4 current (0=1st slide, 1=2nd etc)
		//curindex holds index of currently shown slide (0=1st slide, 1=2nd etc)
	}
})

</script>

</div>
<!--silder Close-->

<div id="midd-start">

<h2>Get Your  <strong>Quote Online </strong></h2>
<p><strong>Tell us about your outsourcing requirements. Simply fill up the following form and we will contact you. If you would prefer to send an email please feel free to contact us at  <a href="mailto:info@ClaimsXperts.com">info@ClaimsXperts.com</a></strong></p>

<div id="contact-us">

<div class="left">
<form name="remodeling.php" method="post">
<label>Name: <b>*</b> </label> <input type="text" name="name" required  value="" /> <br />
 <label>Email ID: <b>*</b> </label> <input type="text"  name="email" required value="" /> <br />
<label>Company Name:  </label> <input type="text" name="company"  value="" /> <br />
<label>Address:  </label> <input type="text" name="address" value="" /> <br />
<label>City:  </label> <input type="text" name="city" value="" /> <br />
<label>State:  </label> <input type="text" name="state" value="" /> <br />
<label>Zip: <b>*</b> </label> <input type="text" name="zip" required value="" /> <br />
<label>Phone Number: <b>*</b> </label> <input type="text" name="phone" required value="" /> <br />
<label>Type of Practice:  <b>*</b> </label><input type="text" name="practice" required value="" /> <br />
<label>No of Physicians:  <b>*</b> </label> <input type="text" name="physicians" required value="" /> <br />
<label>Average Monthly Billing Amount <b>*</b></label><input type="text" name="billing" required value="" /> <br />
<label>How  you hear about us?:  </label> <select name="about">
<option selected="selected" value="0">Select</option>
	<option value="1">Website</option>
	<option value="2" disabled="disabled">Search Engine</option>
	<option value="Google">&nbsp;&nbsp;Google</option>
	<option value="Yahoo">&nbsp;&nbsp;Yahoo</option>
	<option value="MSN">&nbsp;&nbsp;MSN</option>
	<option value="Email Newsletter">Email Newsletter</option>
	<option value="Referral">Referral</option>
	<option value="Word of Mouth">Word of Mouth</option>
	<option value="Email Newsletter" disabled="disabled">Classifieds</option>
	<option value="Craigslist">&nbsp;&nbsp;Craigslist</option>
	<option value="BackPage">&nbsp;&nbsp;BackPage</option>
	<option value="Kijiji">&nbsp;&nbsp;Kijiji</option>
	<option value="Others">&nbsp;&nbsp;Others</option>
	<option value="Magazine/Print Ad's"> Magazine/Print Ad's</option>
	</select> <br />
<label>Comments: <b>*</b> </label> <textarea name="comment" required></textarea>
<label>&nbsp;</label> <input type="submit"name="left" value="submit" class="submit" />
</form>
</div>

<div class="right">
<h2>REACH<strong> US </strong></h2>
<p><strong>Tell us about your outsourcing requirements. Simply fill up the following form and we will contact you. If you would prefer to send an email please feel free to contact us at  <a href="mailto:info@ClaimsXperts.com">info@ClaimsXperts.com</a></strong></p>

<p><b>Phone:</b>  773-829-7198</p>
<p><b>Fax:</b>  773-829-7198</p>
<p><b>Email:</b> <a href="mailto:info@ClaimsXperts.com">info@ClaimsXperts.com</a></p><br />
<p>&nbsp;</p>
<p>&nbsp;</p>
<p>&nbsp;</p>
<p>&nbsp;</p>
</div>

</div>

 


<div class="clear"></div>
</div>

</div>
<!--Middle Close-->


<!--Fotter-->
<div id="fotter">
<p><a href="index.html">Home</a> | <a href="about-us.html">About Us</a>  |  <a href="why-us.html">Why us</a>  |  <a href="pricing.html">Pricing</a>  |  <a href="faq.html">Faq's</a> |  <a href="process-flow.html">Process Flow</a>  | <a href="other-services.html"> Other Services</a></p>
<h3>&copy; Copyright 2013 <a href="index.html">ClaimsXperts</a></h3>
<div class="clear"></div>
</div>
<!--Fotter End-->
</div>

</div>
</body>
</html>
