function checkEmail(email) {
var filter = /^([a-zA-Z0-9_.-])+@(([a-zA-Z0-9-])+.)+([a-zA-Z0-9]{2,4})+$/;
return (filter.test(email)) ;
}


function validate()
{
	var message = "The form has the following errors:\n";
	var errors = false;
	var form = document.getElementById("insurance_form")
	if(!checkEmail(form.email.value))
	{
		errors = true;
		message +="Your email adress needs to be in the form name@example.com\n";
	}

	if(form.address.value == "")
	{
		errors = true;
		message +="You must provide a Street Address\n";
	}
	if(form.city.value == "")
	{
		errors = true;
		message +="You must provide a City\n";
	}
	if(form.state.value == "")
	{
		errors = true;
		message +="You must provide a State or Province or Region\n";
	}
	if(form.zip.value == "")
	{
		errors = true;
		message +="You must provide a Zip or Postal Code\n";
	}
	if(form.contact_name.value == "")
	{
		errors = true;
		message +="You must provide a Contact Name\n";
	}
	
	var ac = form.areacode.value;
	var pre = form.prefix.value;
	var post = form.suffix.value;
	if(ac.length < 3 || pre.length < 3 || post.length < 4)
	{
		errors = true;
		message +="You must provide a Phone Number in the form (555)-555-5555\n";
	}

	if(form.username.value != "")//honeypot
	{
		errors = true;
		message +="\n"
	}
	
	//resopnd to failure by printing error and return false
	if(errors)
	{
    	window.alert (message);
		return false;
	}
	else
		return true;
	
}


function  validate_and_submit()
{
	if(validate())
	{
		
		var form = document.getElementById("insurance_form");
		var form_holder = document.getElementById("form_holder");
		var rent = "No";
		if(form.rental[0].checked)
			rent = 'Yes'; 
		var st = "<form action='insurance_submit.php' method='post' name='insurance_form' id='insurance_form'>"
		+"<div class='form_description'> <p class='black'><strong class='instructions'>Please verify your information and click Send.</strong></p></div>"
		+" <label class='info_verify'>Contact Name: </label> " + form.contact_name.value + " <br/><br/>"
		+" <label class='info_verify'>Insured Name:</label> " + form.insured_name.value + " <br/> "
		+" <label class='info_verify'> Insured's Address:</label><br/>"
		+form.address.value +" "+ form.address2.value+"<br/>"
		+form.city.value+"<br/>"
		+form.state.value+"<br/>"
		+form.zip.value+"<br/>"
		+" <label class='info_verify'>Phone: </label>"+form.areacode.value+"-"+form.prefix.value+"-"+form.suffix.value+"<br/>"
		+"<label class='info_verify'>Email Address: </label>"+form.email.value+"<br/><br/>"
		+" <label class='info_verify'> Need a Rental: </label>"+rent+"<br/><br/>"
	
		+"<br/>"
		+"<label class='info_verify'>Insurance Claim</label><br/>"
		+"<label class='info_verify'>Insrance Company: </label>"+form.insurance_name.value+"<br/>"
		+"<label class='info_verify'>Policy Number: </label>"+form.policy_number.value+"<br/>"
		+"<label class='info_verify'>Claim Number: </label>"+form.claim_number.value+"<br/>"
		+"<label class='info_verify'>Date of Accident: </label>"+form.accident_month.value+"/"+form.accident_dt.value+"/"+form.accident_year.value+"<br/>"
		+"<label class='info_verify'>Adjuster's Phone: </label>"+form.areacode2.value+"-"+form.prefix2.value+"-"+form.suffix2.value+"<br/><br/>"
		+"<label class='info_verify'> Additional Information:</label><br/>"+form.additional_info.value
		
		+"<br/><input type='hidden' name='contact_name' value='"+form.contact_name.value+"'>"
		+"<input type='hidden' name='insured_name' value='"+form.insured_name.value+"'>"
		
		+"<input type='hidden' name='areacode' value='"+form.areacode.value+"'>"
		+"<input type='hidden' name='prefix' value='"+form.prefix.value+"'>"
		+"<input type='hidden' name='suffix' value='"+form.suffix.value+"'>"
		
		+"<input type='hidden' name='email' value='"+form.email.value+"'>"
		
		+"<input type='hidden' name='rental' value='"+rent+"'>"
		
		+"<input type='hidden' name='address' value='"+form.address.value+"'>"
		+"<input type='hidden' name='address2' value='"+form.address2.value+"'>"
		+"<input type='hidden' name='city' value='"+form.city.value+"'>"
		+"<input type='hidden' name='state' value='"+form.state.value+"'>"
		+"<input type='hidden' name='zip' value='"+form.zip.value+"'>"
		
		
		+"<input type='hidden' name='insurance_name' value='"+form.insurance_name.value+"'>"
		+"<input type='hidden' name='policy_number' value='"+form.policy_number.value+"'>"
		+"<input type='hidden' name='claim_number' value='"+form.claim_number.value+"'>"
		
		+"<input type='hidden' name='accident_month' value='"+form.accident_month.value+"'>"
		+"<input type='hidden' name='accident_dt' value='"+form.accident_dt.value+"'>"
		+"<input type='hidden' name='accident_year' value='"+form.accident_year.value+"'>"
		
		+"<input type='hidden' name='areacode2' value='"+form.areacode2.value+"'>"
		+"<input type='hidden' name='prefix2' value='"+form.prefix2.value+"'>"
		+"<input type='hidden' name='suffix2' value='"+form.suffix2.value+"'>"
		
		+"<input type='hidden' name='additional_info' value='"+	form.additional_info.value+"'>"
	
          +"<p class='instructions'>Please click the 'Send' button only once. Depending upon the speed of your internet connection, it may take a few second to process your submission.</p>"
	 +"<input type='submit' value='Send' ><input type='button' value='Go Back' onclick='revert_form()'></form><br/><br/>";
	 form_holder.innerHTML = st;
	  window.scroll(0,0);
	}
	
}

function send_form(){
	var form = document.getElementById("contact_form");
	form.submit();
}

function revert_form(){
window.location.reload();
}