<form method="POST" action="/ex/ex_post.jsp">
<input type=hidden name="post_url" value="@system.providerurl@">
<input type=hidden name="update_fieldid" value="2704332">
<input type=hidden name="ss_CaseID" value="@parent.opportunityid@">
<input type=hidden name="ss_ServiceID" value="@eventid@">
<input type=hidden name="ss_CustomerID" value="ID goes here">
<input type=hidden name="ss_Source" value="10">
<input type=hidden name="newlevelthree" value="1">
<input type=hidden name="subject" value="providername">
<input type=hidden name="description" value="">
<input type=hidden name="statusid" value="31064">
<input type=hidden name="eventtype" value="46852">
<input type=hidden name="appid" value="103115">
<input type=hidden name="referencefield" value="2704345">
<div style="border:1px solid #1b409b; max-width:700px; min-width:550px;">
<table>
<td><textarea name=ss_PickupPostalCode readonly>@piczip@</textarea></td>
<!--@end-->
</tr>
<tr>
<th align="left"> Pickup Apt. /Suite</th>
<td><textarea name=ss_PickupApt readonly><!--hideifnotfound-->@Pickup-Apt@</textarea></td>
<th align="left"> Pickup Buzzer Code</th>
<td><textarea name=ss_PickupBuzzer readonly><!--hideifnotfound-->@Pickup-Buzzer@</textarea></td>
</tr>
<tr>
<td><textarea name=ss_PickupPhone readonly><!--hideifnotfound-->@Pickup-Phone@</textarea></td>
<!--@end-->
</tr>
<tr>
<th align="left"> Does Claimant Require a Wheelchair Accessible Vehicle?</th>
<td><input type='hidden' name='ss_WheelchairVehicle' value='@intwheel.combovalue@'>
<textarea readonly>@intwheel@</textarea></td>
<th align="left"> Does Claimant Require Special Needs (e.g. Assistance)?</th>
<td><input type='hidden' name='ss_SpecialNeeds' value='@intassistance.combovalue@'>
<textarea readonly>@intassistance@</textarea></td>
</tr>
<th colspan="4" align="left" class="titleText001"><br /><br />Claimant Information </th>
<th align="left"> City </th>
<td><textarea name=ss_ClaimantCity readonly><!--hideifnotfound-->@parent.Claimant City@</textarea></td>
</tr>
<tr>
<th align="left"> Apt. /Suite </th>
<td><textarea name=ss_ClaimantApt readonly><!--hideifnotfound-->@parent.Claimant Apt@</textarea></td>
<th align="left"> Buzzer Code</th>
<td><textarea name=ss_ClaimantBuzzer readonly><!--hideifnotfound-->@parent.Claimant Buzzer@</textarea></td>
</tr>
<tr>
<th align="left"> Country </th>
<td><textarea name=ss_ClaimantCountry readonly><!--hideifnotfound-->Canada</textarea></td>
<th align="left"> P.O Box </th> <td><textarea name=ss_ClaimantPOBox readonly><!--hideifnotfound-->@parent.Claimant P.O Box@</textarea></td> </tr> <tr> <th align="left">Phone </th>
<td><textarea name=ss_ClaimantPhone readonly><!--hideifnotfound-->@parent.Claimant Phone #@</textarea></td>
<th align="left">Fax Number </th>
<td><textarea name=ss_ClaimantFax readonly><!--hideifnotfound-->@parent.Claimant Fax #@</textarea></td>
</tr>
<tr>
<th align="left">Policy #</th>
</body>
</html>
