_err; MyFormCheck::check_email($email); $err .= $MyFormCheck->_err; if($err == ''){ include "lphp.php"; $mylphp=new lphp; # constants $myorder["host"] = "secure.linkpt.net"; $myorder["port"] = "1129"; $myorder["keyfile"] = realpath("1215520.pem"); # Change this to the name and location of your certificate file $myorder["configfile"] = "1215520"; # Change this to your store number # transaction details $myorder["ordertype"] = "SALE"; $myorder["result"] = "LIVE"; //$myorder["cbin"] = "true"; //$myorder["xml_output"] = "true"; $myorder["cpath"] = "/usr/bin/curl"; $myorder["chargetotal"] = $_POST["chargetotal"]; # card info $myorder["cardnumber"] = $_POST["cardnumber"]; $myorder["cardexpmonth"] = $_POST["cardexpmonth"]; $myorder["cardexpyear"] = $_POST["cardexpyear"]; $myorder["cvmindicator"] = "provided"; $myorder["cvmvalue"] = $_POST["cvmvalue"]; # BILLING INFO $myorder["name"] = htmlspecialchars($_POST["name"]); $myorder["company"] = htmlspecialchars($_POST["company"]); $myorder["address1"] = htmlspecialchars($_POST["address1"]); $myorder["address2"] = htmlspecialchars($_POST["address2"]); $myorder["city"] = htmlspecialchars($_POST["city"]); $myorder["state"] = htmlspecialchars($_POST["state"]); $myorder["country"] = "US"; $myorder["phone"] = htmlspecialchars($_POST["Telephone"]); $myorder["fax"] = htmlspecialchars($_POST["fax"]); $myorder["email"] = htmlspecialchars($_POST["email"]); $myorder["addrnum"] = htmlspecialchars($_POST["addrnum"]); $myorder["zip"] = htmlspecialchars($_POST["zip"]); # SHIPPING INFO $myorder["sname"] = htmlspecialchars($_POST["sname"]); $myorder["saddress1"] = htmlspecialchars($_POST["saddress1"]); $myorder["saddress2"] = htmlspecialchars($_POST["saddress2"]); $myorder["scity"] = htmlspecialchars($_POST["scity"]); $myorder["sstate"] = htmlspecialchars($_POST["sstate"]); $myorder["szip"] = htmlspecialchars($_POST["szip"]); $myorder["scountry"] = "US"; # MISC $myorder["comments"] = htmlspecialchars($_POST["comments"]); $myorder["referred"] = "Insurance Carrier: ".htmlspecialchars($_POST["Carrier"]).", Policy Number: ".htmlspecialchars($_POST["Policy_Number"]); # Send transaction. Use one of two possible methods // $result = $mylphp->process($myorder); # use shared library model $result = $mylphp->curl_process($myorder); # use curl methods if ($result["r_approved"] != "APPROVED") // transaction failed, print the reason { if ($result["r_approved"] != "APPROVED" && strstr($result['r_error'], 'D:Declined')) { $err .= 'Your credit card was declined. Please try another card or contact your bank for more info.'; } elseif ($result["r_approved"] != "APPROVED" && strstr($result['r_error'], 'R:Referral')) { $err .= 'Your credit card was declined. Please try another card or contact your bank for more info.'; } elseif ($result["r_approved"] != "APPROVED" && strstr($result['r_error'], 'Duplicate transaction')) { $err .= 'It appears you submitted your order more than once. If it was previously declined please wait 10 minutes.'; } elseif ($result["r_approved"] != "APPROVED" && strstr($result['r_error'], 'SGS')) { $err .= $result["r_error"]; } elseif ($result["r_approved"] != "APPROVED" ) { $err .= $result["r_error"]; $err .= 'There has been an error processing you credit card, please wait 10 minutes before trying again.'; } $logy = "./linkpoint.out"; foreach ($result as $key1 => $value1) { $erry .= "\n\t".$key1.":\t".$value1." "; } if ( $fp1y = @fopen($logy,'a') ) { fwrite($fp1y, sprintf("\r\n%s", $erry)); fclose($fp1y); } } else // success { if ($result["r_approved"] == "APPROVED") // transaction failed, print the reason { $t=time(); $d = date("F d, Y"); $from_email = "payment@insureusa.com"; $subject = "InsureUSA Insurance Payment Confirmation"; $message = implode('', file("receipt.html")); $message = str_replace("[DATE]",$d,$message); $message = str_replace("[sname]",$_POST['sname'],$message); $message = str_replace("[saddress1]",$_POST['saddress1'],$message); $message = str_replace("[saddress2]",$_POST['saddress2'],$message); $message = str_replace("[scity]",$_POST['scity'],$message); $message = str_replace("[szip]",$_POST['szip'],$message); $message = str_replace("[sstate]",$_POST['sstate'],$message); $message = str_replace("[Carrier]",$_POST['Carrier'],$message); $message = str_replace("[Policy_Number]",$_POST['Policy_Number'],$message); $message = str_replace("[chargetotal]",$_POST['chargetotal'],$message); $message = str_replace("[Telephone]",$_POST['Telephone'],$message); $message = str_replace("[email]",$_POST['email'],$message); $message = str_replace("[comments]",$_POST['comments'],$message); /****** Mail to Customer ***********/ MyMail::my_send_mail( $_POST['email'], $subject, $message, $from_email, "InsureUSA.com"); $err .= $MyMail->_err; /****** Mail to Admin ***********/ $subject = "InsureUSA Website CC Payment"; $from_email = "payment@insureusa.com"; MyMail::my_send_mail( $from_email, $subject, $message, $_POST['email'], "InsureUSA.com"); $err .= $MyMail->_err; $_SESSION['customer_email'] = $_POST['email']; header("Location:secure-form-thanks.htm"); exit(); } else { $err .= "Payment is not approved. It is decliend by yourpay."; } }// end if ($result["r_approved"] != "APPROVED") } } ?> <?php echo $pageTitle;?>
 
Atlanta, Georgia

Credit Card Secure Payment Form

Our secure server encrypts your information, ensuring that your credit card data stays private and protected.

If your policy was already cancelled, your credit card payment will not automatically reinstate your policy.

Once you complete this form, and submit your payment information to our secure server, we will send you an email confirmation receipt to the email address you indicate below.

* indicates a required field

       
 

CUSTOMER INFORMATION

  Name: * " />  
  Address: * " />
  Address 2: " />
  City *, State *, Zip *: " /> ,   " />
  Telephone: " />
  Email: *  

" />

   
 


PAYMENT INFORMATION

  Insurance Carrier: * " />
  Policy Number: * " />
  Payment Amount: * " />
   
 


CREDIT CARD BILLING INFORMATION

  Name on Card: * " />  
  Company: (if appl.) " />
   
  check if credit card billing address is the same as the Customer Address
   
  Address: *
 " />
  Address 2:
" />
  City *, State *, Zip *: " /> ,   " />
     
  Credit Card Number: *
  Expiration Date: * / 
  Security Code (CVV): *


Visa/MC: 3-digit code that follows your card
number in the signature panel.
Amex: 4-digit code on the front; right of card number.
     
 


ADDITIONAL COMMENTS