document.write("<!-- Web Form Generator 2.0 --><center><form method=\"post\" action=\"http://clients.xmailpro.com/scripts/addlead.pl\" target=\"_new\"><input type=\"hidden\" name=\"meta_web_form_id\" value=\"1221535752\"><input type=\"hidden\" name=\"meta_split_id\" value=\"\"><input type=\"hidden\" name=\"unit\" value=\"chicagoglass\"><input type=\"hidden\" name=\"redirect\" value=\"http://clients.xmailpro.com/thankyou-coi.htm?m=audio\" id=\"redirect_64ba4dccba957bbc641724713bf2a18f\"><input type=\"hidden\" name=\"meta_redirect_onlist\" value=\"\"><input type=\"hidden\" name=\"meta_adtracking\" value=\"Homepage\"><input type=\"hidden\" name=\"meta_message\" value=\"1\"><input type=\"hidden\" name=\"meta_required\" value=\"name,from,custom Phone (with area code),custom Year-Make-Model,custom Glass Type\"><input type=\"hidden\" name=\"meta_forward_vars\" value=\"0\"><table><tr><td colspan=2><center><div align=\"center\"><h2><font color=\"#990033\" face=\"Georgia\"><strong>**FAST GLASS QUOTE**</strong></font><br></h2></div></center></td></tr><tr><td>* Name:</td><td><input type=\"text\" name=\"name\" value=\"\" size=\"20\"></td></tr><tr><td>* Email:</td><td><input type=\"text\" name=\"from\" value=\"\" size=\"20\"></td></tr><tr><td>* Phone (xxx-xxx-xxxx):</td><td><input type=\"text\" name=\"custom Phone (with area code)\" value=\"\" size=\"20\"></td></tr><tr><td>* Year/Make/Model:</td><td><input type=\"text\" name=\"custom Year-Make-Model\" value=\"\" size=\"20\"></td></tr><tr><td>* Glass Type:</td><td><select name=\"custom Glass Type\"><option value=\"Select One\">Select One</option><option value=\"WINDSHIELD\">WINDSHIELD</option><option value=\"REAR GLASS\">REAR GLASS</option><option value=\"VENT GLASS\">VENT GLASS</option><option value=\"DRIVER SIDE-Front\">DRIVER SIDE-Front</option><option value=\"DRIVER SIDE-Rear\">DRIVER SIDE-Rear</option><option value=\"PASS SIDE-Front\">PASS SIDE-Front</option><option value=\"PASS SIDE-Rear\">PASS SIDE-Rear</option><option value=\"SUNROOF\">SUNROOF</option></select></td></tr>    <tr><td colspan=2><center><div align=\"center\"><h3><font size=\"4\" color=\"#0000cc\"><br>INSURANCE CLAIMS WELCOME</font></h3><div><strong>You will receive a confirmation message<br> after clicking \"Submit\"</strong></div><div><strong>&nbsp;</strong></div><div><strong>Check your email immediately to proceed.</strong><font size=\"5\" color=\"#990000\"> <br></font></div></div></center></td></tr><tr><td align=\"center\" colspan=\"2\"><input type=\"submit\" name=\"submit\" value=\"Submit\"></td></tr></table></form></center>");

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