document.write('<form method="post" name="form1" style="vertical-align:top;" action="/visitor-medical-insurance-quotes.asp">');
document.write('    <fieldset>');
document.write('      <div class="row-form">');
document.write('        <label for="lab1">Traveler\'s Age</label>');
document.write(' <div>');
document.write('    <input name="Age" type="text" id="age" onkeypress="return numbersonly(event);" maxlength="2" class="middle" value="" />');
document.write('</div>');
document.write('</div>');
document.write('<div class="row-form">');
document.write('        <label for="lab2">');
document.write('          Spouse Age (if required)');
document.write('    </label>');
document.write('        <div>');
document.write('          <input type="text" name="spouseAge" onkeypress="return numbersonly(event);" maxlength="2" class="middle" value="" />');
document.write('    </div>');
document.write('</div>');
document.write('      <div class="row-form">');
document.write('        <span title="max coverage reqd">Max Coverage Reqd</span>');
document.write('        <div>');
document.write('          <select name="MaxPolicyLimit" size="1" title="select">');
document.write('            <option value="0-25000">$25,000 or less </option>');
document.write('            <option value="26000-60000" selected="selected">$26K to $60K</option>');
document.write('            <option value="61000-100000">$61K to $100K</option>');
document.write('            <option value="101000-499000">$101K to $499K</option>');
document.write('            <option value="500000">$500,000</option>');
document.write('            <option value="1000000">$1,000,000</option>');
document.write('</select>');
document.write('  </div>');
document.write('</div>');
document.write('        <div class="row-form">');
document.write('          <span title="coverage period">Coverage Period</span>');
document.write('          <div>');
document.write('            <input name="monthsOfCoverage" type="text" onkeypress="return numbersonly(event);" value="1" id="lab3" class="small" title="Coverage Period Months" />');
document.write('            <label for="lab3">Mon</label>');
document.write('            <input name="daysOfCoverage" type="text" onkeypress="return numbersonly(event);" value="0" id="lab4" class="small" title="Coverage Period Days" />');
document.write('            <label for="lab4">Day</label>');
document.write('    </div>');
document.write('  </div>');
document.write('        <div class="row-form">');
document.write('          <span title="citizenship">Citizenship</span>');
document.write('          <div>');
document.write('            <input  type="radio" name="CountryofCitizenship" value="2" checked="checked" onclick="document.form1.CountryforCoverage.value=1;" id="lab5" class="radio" title="Non-US" />');
document.write('            <label for="lab5">Non Us</label>');
document.write('            <input id="lab6" class="radio" type="radio" name="CountryofCitizenship" value="1" onclick="document.form1.CountryforCoverage.value=4;" title="US" />');
document.write('            <label for="lab6">US</label>');
document.write('    </div>');
document.write('  </div>');
document.write('        <div class="row-form button">');
document.write('          <input type="button" onclick="validatemini();" name="quote" value="Get Quote!" style="width: 75px;" />');
document.write('          <input type="button" onclick="gomain();" name="quote2" value="More Options" style="width: 95px;" />');
document.write('          <input type="hidden" name="Deductible" value="101-250"/>');
document.write('          <input type="hidden" name="NumberOfChildren" value="0"/>');
document.write('          <input type="hidden" name="CountryforCoverage" value="1"/>');
document.write('          <input type="hidden" name="MailingAddress" value="2"/>');
document.write('          <input type="hidden" name="Residence" value="2"/>');
document.write('          <input type="hidden" name="USarrival" value="5"/>');
document.write('          <input type="hidden" name="P"/>');
document.write('          <input type="hidden" name="S"/>');
document.write('          <input type="hidden" name="mths"/>');
document.write('          <input type="hidden" name="dys"/>');
document.write('          <input type="hidden" name="x"/>');
document.write('          <input type="hidden" name="us"/>');
document.write(' <input name="affiliate" type="hidden" value="ivisi">');
document.write('</div>');
document.write('</fieldset>');
document.write('</form>');