_err; MyFormCheck::check_email($customer_email); $err .= $MyFormCheck->_err; if($user_agree != 'Yes'){ $err .= '
You have to agree authorization statement.'; } if($err == ''){ $DEBUGGING = 1; # Display additional information to track down problems $TESTING = 1; # Set the testing flag so that transactions are not live $ERROR_RETRIES = 2; # Number of transactions to post if soft errors occur $auth_net_login_id = "4n8m2QXE"; $auth_net_tran_key = "45EYzyyxBd4798DV"; $auth_net_url = "https://secure.authorize.net/gateway/transact.dll"; # Uncomment the line ABOVE for test accounts or BELOW for live merchant accounts //Test Account // $auth_net_login_id = "54PB5egZ"; // $auth_net_tran_key = "48V258vr55AE8tcg"; // $auth_net_url = "https://test.authorize.net/gateway/transact.dll"; $authnet_values = array ( "x_login" => $auth_net_login_id, "x_version" => "3.1", "x_delim_char" => "|", "x_delim_data" => "TRUE", "x_type" => "AUTH_CAPTURE", "x_method" => "ECHECK", "x_tran_key" => $auth_net_tran_key, "x_relay_response" => "FALSE", "x_bank_aba_code" => $ABARoutingNumber, "x_bank_acct_num" => $AccountNumber, "x_bank_acct_type" => $AccountType, "x_bank_name" => $BankName, "x_bank_acct_name" => $AccountName, "x_echeck_type" => "WEB", "x_amount" => $chargetotal, "x_first_name" => $sname, "x_last_name" => "", "x_address" => htmlspecialchars($saddress1), "x_city" => $scity, "x_state" => $sstate, "x_zip" => $szip, "x_country" => "USA", "x_phone" => $Telephone, "x_email" => $customer_email, "x_customer_ip" => $_SERVER['REMOTE_ADDR'], "Insurance_Carrier" => htmlspecialchars($_POST["Carrier"]), "Policy_Number" => htmlspecialchars($_POST["Policy_Number"]), "Comments" => htmlspecialchars($_POST["comments"]), ); $fields = ""; while(list($key, $value) = each($authnet_values)) { $data .= $key . '=' . urlencode(ereg_replace(',', '', $value)) . '&'; } // Remove the last "&" from the string $data = substr($data, 0, -1); //exec("/usr/bin/curl -k -d '$data' $auth_net_url", $response); $request = curl_init($auth_net_url); // initiate curl object curl_setopt($request, CURLOPT_HEADER, 0); // set to 0 to eliminate header info from response curl_setopt($request, CURLOPT_RETURNTRANSFER, 1); // Returns response data instead of TRUE(1) curl_setopt($request, CURLOPT_POSTFIELDS, $data); // use HTTP POST to send form data curl_setopt($request, CURLOPT_SSL_VERIFYPEER, FALSE); // uncomment this line if you get no gateway response. $post_response = curl_exec($request); // execute curl post and store results in $post_response // This line takes the response and breaks it into an array using the specified delimiting character $result = explode($authnet_values['x_delim_char'], $post_response); //print_r($authnet_response); //add this line. //$result = explode(",", urldecode($response[0])); $resp = $result[0]; $text = $resp; $tok = strtok($text,"|"); while(!($tok === FALSE)){ $tok = strtok("|"); } $text = $resp; $h = substr_count($text, "|"); $h++; for($j=1; $j <= $h; $j++){ $p = strpos($text, "|"); if ($p === false) { // note: three equal signs }else{ $p++; $pstr = substr($text, 0, $p); $pstr_trimmed = substr($pstr, 0, -1); // removes "|" at the end if($pstr_trimmed==""){ $pstr_trimmed="NO VALUE RETURNED"; } switch($j){ case 1: $fval=""; if($pstr_trimmed=="1"){ $fval="Approved"; $success_payment = "Approved"; }elseif($pstr_trimmed=="2"){ $fval="Declined"; }elseif($pstr_trimmed=="3"){ $fval="Error"; } break; case 2: break; case 3: $response_reason_text = $result[3]; break; case 4: $response_reason_text = $pstr_trimmed; break; case 39: $fval=""; if($pstr_trimmed=="M"){ $fval="M = Match"; }elseif($pstr_trimmed=="N"){ $fval="N = No Match"; }elseif($pstr_trimmed=="P"){ $fval="P = Not Processed"; }elseif($pstr_trimmed=="S"){ $fval="S = Should have been present"; }elseif($pstr_trimmed=="U"){ $fval="U = Issuer unable to process request"; }else{ $fval="NO VALUE RETURNED"; } break; default: break; } // remove the part that we identified and work with the rest of the string $text = substr($text, $p); }// if ($p === false) }// end for($j=1; $j <= $h; $j++) if($success_payment != 'Approved') { $err = $response_reason_text; if(strlen($response_reason_text)<=0){ $err = $result[3]; } if(strpos($err,'approved.')>0){ $t=time(); $d = date("F d, Y"); $from_email = "payment@insureusa.com"; $subject = "InsureUSA Insurance echeck Payment Confirmation"; $message = implode('', file("echeck_receipt.html")); $message = str_replace("[DATE]",$d,$message); $message = str_replace("[sname]",$_POST['sname'],$message); $message = str_replace("[saddress1]",$_POST['saddress1'],$message); $message = str_replace("[acc_type_1]",$_POST['acc_type_1'],$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); $message = str_replace("[customer_email]",$_POST['customer_email'],$message); $message = str_replace("[customer_signature]",$_POST['customer_signature'],$message); $message = str_replace("[comments]",$_POST['comments'],$message); /****** Mail to Customer ***********/ MyMail::my_send_mail( $_POST['customer_email'], $subject, $message, $from_email, "InsureUSA.com"); $err .= $MyMail->_err; /****** Mail to Admin ***********/ $subject = "InsureUSA Website Echeck Payment"; $from_email = "payment@insureusa.com"; MyMail::my_send_mail( $from_email, $subject, $message, $_POST['customer_email'], "InsureUSA.com"); $err .= $MyMail->_err; $_SESSION['customer_email'] = $_POST['customer_email']; header("Location:secure-form-thanks.htm"); } } elseif($success_payment == 'Approved'){ $t=time(); $d = date("F d, Y"); $from_email = "payment@insureusa.com"; $subject = "InsureUSA Insurance echeck Payment Confirmation"; $message = implode('', file("echeck_receipt.html")); $message = str_replace("[DATE]",$d,$message); $message = str_replace("[sname]",$_POST['sname'],$message); $message = str_replace("[saddress1]",$_POST['saddress1'],$message); $message = str_replace("[acc_type_1]",$_POST['acc_type_1'],$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); $message = str_replace("[customer_email]",$_POST['customer_email'],$message); $message = str_replace("[customer_signature]",$_POST['customer_signature'],$message); $message = str_replace("[comments]",$_POST['comments'],$message); /****** Mail to Customer ***********/ MyMail::my_send_mail( $_POST['customer_email'], $subject, $message, $from_email, "InsureUSA.com"); $err .= $MyMail->_err; /****** Mail to Admin ***********/ $subject = "InsureUSA Website Echeck Payment"; $from_email = "payment@insureusa.com"; MyMail::my_send_mail( $from_email, $subject, $message, $_POST['customer_email'], "InsureUSA.com"); $err .= $MyMail->_err; $_SESSION['customer_email'] = $_POST['customer_email']; header("Location:secure-form-thanks.htm"); exit(); } else{ $err = "Payment is not approved. It is decliend by payment gateway."; } }// if($err == '') }//if(isset($_POST['submit']) && $_POST['submit']!='' ) ?> <?php echo $pageTitle;?>

Atlanta, Georgia

Electronic Check Secure Payment Form

Accept Electronic Check

* indicates a required field

CUSTOMER INFORMATION

Name: *

" />

Address: *

" />

City *, State *, Zip *:

" /> , " />

Telephone:

" />

Email: *

" />

PAYMENT INFORMATION

Insurance Carrier: *

" />

Policy Number: *

" />

Payment Amount: *

" />

ELECTRONIC CHECK

Bank ABA Routing Number: *

" />

Bank Name: *

" />

Account Number: *

" />

Bank Account Name: *

" />

Account Type: *

Please select Agree below to accept the terms and conditions of the Authorization Statement. Once you select Agree, the blanks fields below will be filled-in automatically.

AUTHORIZATION STATEMENT

On this day, " />, I authorize InsureUSA Insurance Agency to charge my " /> account one-time to pay my insurance premium for the above-referenced insurance policy for the amount of $ " />.
I have provided my " /> account information above.

I understand and agree that this debit to my account may be conducted by ACH, electronic funds transfer or demand draft and that funds may be removed from my " /> account as soon as today. In addition, I understand and agree that if any of my payments are returned unpaid, I also authorize the collection of a returned item fee of $25.00 by presenting a demand draft against my account or by making a one-time electronic fund transfer from my account.

onClick="javascript:post_data('Yes');" >Agree onClick="javascript:post_data('No');" >Disagree

" />

[Customer Signature] (* Please type your name (First Name and Last Name) between two forward slashes (example: /John Doe/)

" />
[Customer Printed Name]

" />
[Date Signed]

ADDITIONAL COMMENTS