</head>
<body bgcolor="#FFFFFF" link=blue vlink=purple class="Normal" lang=EN-US topmargin="25" bottommargin="25" leftmargin="30" rightmargin="30">
<form method="POST" action="/ex/ex_post.jsp">
<input type=hidden name="post_url" value="@system.providerurl@">
<input type=hidden name="appid" value="103115">
<input type=hidden name="referencefield" value="2704345">
<BR>
<div style="border:1px solid #1b409b; max-width:700px; min-width:550px;">
<table>
<th align="left"> Date of Loss </th>
<td><textarea name=ss_DateofLoss readonly>@parent.Date of Loss@</textarea></td>
</tr>
<tr>
<th colspan="4" align="left" class="titleText001">Billing Details</th>
</tr>
<tr>
<th align="left"> Billing Same as Insurer / Referral company</th>
<td><input type='hidden' name='ss_Billingsameasreferral' value='@billsamereferral.combovalue@'>
<textarea readonly>@billsamereferral@</textarea></td>
</tr>
<!--@sslogic('@billsamereferral@'='No')-->
<tr>
<th align="left"> First Name (Billing)</th>
<td><textarea name=ss_BillingFirstName readonly>@bilfirstname@</textarea></td>
<th align="left"> Last Name (Billing)</th>
<td><textarea name=ss_BillingLastName readonly>@bilastname@</textarea></td>
</tr>
<tr>
<th align="left"> Company (Billing)</th>
<td><textarea name=ss_BillingCompany readonly>@bilcompany@</textarea></td>
<th align="left"> Address (Billing)</th>
<td><textarea name=ss_BillingAddress readonly>@biladdress@</textarea></td>
</tr>
<tr>
<th align="left"> City (Billing)</th>
<td><textarea name=ss_BillingCity readonly>@bilcity@</textarea></td>
<th align="left"> Province Code/Zip (Billing)</th>
<td><textarea name=ss_BillingProvince/state readonly>@bilprovince@</textarea></td>
</tr>
<tr>
<th align="left"> Postal Code/Zip (Billing)</th>
<td><textarea name=ss_BillingPostalCode readonly>@bilzip@</textarea></td>
<th align="left"> P.O.Box(Billing) </th>
<td><textarea name=ss_BillingP.O.Box readonly>@bilpobox@</textarea></td>
</tr>
<tr>
<th align="left"> Phone (Billing)</th>
<td><textarea name=ss_BillingPhone readonly>@bilphone@</textarea></td>
<th align="left"> Fax(Billing)</th>
<td><textarea name=ss_BillingFax readonly>@bilfax@</textarea></td>
</tr>
<tr>
<th align="left"> Email</th>
<td><textarea name=ss_BillingEmail readonly>@bilemail@</textarea></td>
</tr>
<!--@end-->
<tr>
<th colspan="4" align="left" class="titleText001">Appointment Confirmation</th>
</tr>
<tr>
<th align="left"> Fax confirmation of appointment</th>
<td><input type='hidden' name='ss_Faxconfirmationofappointment' value='@faxconf.combovalue@'>
<textarea readonly>@faxconf@</textarea></td>
<th align="left"> Phone Confirmation</th>
<td><input type='hidden' name='ss_Phoneconfirmationofappointment' value='@phoneconf.combovalue@'>
<textarea readonly>@phoneconf@</textarea></td>
</tr>
<tr>
<th align="left"> Email confirmation of appointment</th>
<td><input type='hidden' name='ss_Emailconfirmationofappointment' value='@emailconf.combovalue@'>
<textarea readonly>@emailconf@</textarea></td>
<th align="left"> Notes</th>
<th><textarea name=ss_Notes readonly><!--hideifnotfound-->@Service Notes@</textarea>
</th>
</tr>
</table>
