document.write('<form method="post" name="form1" action="/visitor-medical-insurance-quotes.asp" onSubmit="validate();" valign="top" class="boxclass">');
document.write('		<table border="0" cellspacing="0" cellpadding="5">');
document.write(	'		    <tr id="row">');
document.write('			    <td id="pad1">&nbsp;1.</td>');
document.write('				<td id="pad2">Enter the age of the traveler or visitor</td>');
document.write('				<td colspan="8" id="pad">');
document.write('					<input size="2" name="Age" id="Age" onKeyPress="return numbersonly(event);" onkeyup="priorCvgQuestion();" maxlength="2"/>');
document.write('					<input name="affiliate" type="hidden" value="ivisi"></td>');
document.write('	  </tr>');
document.write('	  <tr id="row1">');
document.write('         	<td  id="pad1">&nbsp;2.</td>');
document.write('	    	<td id="pad2">Enter age of the traveler&rsquo;s spouse if coverage for spouse is required</td>');
document.write('	   		<td colspan="8" id="pad">');
document.write('	   			<input size="2" name="spouseAge" id="spouseAge" onKeyPress="return numbersonly(event);" onkeyup="priorCvgQuestion();" maxlength="2"/></td>');
document.write('	  </tr>');
document.write('		<tr id="row">');
document.write('          	 <td id="pad1">&nbsp;3. </td>');
document.write('		  	 <td id="pad2">Enter number &amp; ages of dependents under 18 requiring coverage');
document.write('			     <span class="smallFont">&nbsp;(Child less than 18 years and accompanied by a parent or guardian.)</span></td>');
document.write('		  	<td id="pad">');
document.write('             	<select name="NumberOfChildren" id="NumberOfChildren" onChange="showtextbox(this.selectedIndex);">');
document.write(getNoChildrenHTML()); 
document.write('				</select>');
document.write('	     	</td>');
document.write(getDependantCellHTML());
document.write('		</tr>');
document.write('        <tr id="row1">');
document.write('              <td id="pad1">&nbsp;4. </td>');
document.write('              <td id="pad2">Select the coverage limit for medical expenses');
document.write('                  <span class="smallFont">&nbsp;(Maximum that the plan will cover)</span></td>');
document.write('             <td id="pad" colspan="8"><select name="MaxPolicyLimit" id="MaxPolicyLimit">');
		var maxpolLim = new Array("0-25000","26000-60000", "61000-75000", "76000-100000", "101000-499000", "500000","1000000","5000000","8000000");
		var mpl = new Array("$25,000 or less","$26,000 to $60,000","$61,000 to $75,000","$76,000 to $100,000","$101,000 to $499,000","$500,000","$1,000,000","$5,000,000","$8,000,000");
document.write(getMaxPolLimitHTML(maxpolLim, mpl, "26000-60000"));  
document.write('            </select></td>');
document.write('        </tr>');
document.write('        <tr id="row">');
document.write('            <td id="pad1">&nbsp;5.</td>');
document.write('            <td id="pad2">Select the deductible amount ');
document.write('				<span class="smallFont">(The initial amount that you are responsible for before the insurance pays for medical expense.)</span></td>');
document.write('            <td id="pad" colspan="8"><select name="Deductible" id="Deductible">');
var vdeductible=new Array("0","50-100", "101-250", "500", "1000", "2500", "5000","10000", "25000");
var vdbl = new Array("US$ 0","US$ 50 to 100","US$ 101 to 250","US$ 500","US$ 1000 ","US$ 2500 ","US$ 5000 ","US$ 10000 ","US$ 25000 ");
document.write(getDeductibleHTML(vdeductible, vdbl, "101-250"));
document.write('                 </select></td>');
document.write('         </tr>');
document.write('         <tr id ="row1">');
document.write('             <td id="pad11">&nbsp;6. </td>');
document.write('             <td id="pad22">Select the dates for coverage </td>');
document.write(' 				   <td colspan="8" id="pad"><div>');
document.write('                       <select name="DepartureMonth"  id="DepartureMonth" onChange="setperiods();">');
document.write(getMonthHTML());
document.write('                      </select>');
document.write('                      <select name="DepartureDay" id="DepartureDay" onChange="setperiods();">');
document.write(getDayHTML());
document.write('                      </select>');
document.write('                      <select name="DepartureYear" id="DepartureYear" onChange="setperiods();">');
document.write(getYearHTML());
document.write('                      </select>');
document.write(' 				      </div>');
document.write(' 				      <select name="ReturnMonth" id="ReturnMonth" onChange="setperiods();">');
document.write(getMonthHTML());
document.write('                      </select>');
document.write('                      <select name="ReturnDay" id="ReturnDay" onChange="setperiods();">');
document.write(getDayHTML());
document.write('                      </select>');
document.write('                      <select name="ReturnYear" id="ReturnYear" onChange="setperiods();">');
document.write(getYearHTML());
document.write('                      </select>&nbsp;');
document.write('                      <input type="text" name="monthsOfCoverage" id="monthsOfCoverage" onChange="if(this.value < 0)this.value=0" readonly="true" size="1">  months');
document.write(' 				      <input type="text" name="daysOfCoverage" id="daysOfCoverage" readonly="true" onChange="if(this.value < 0)this.value=0" size="1">  days	');			        
document.write(' 			          </td>');
document.write('        </tr>');
document.write('        <tr id="row">');
document.write('              <td  id="pad1">&nbsp;7. </td>');
document.write('              <td  id="pad2">Select the visitor/traveler&#39;s country of citizenship	</td>');
document.write('              <td id="pad" colspan="8"><select name="CountryofCitizenship" id="CountryofCitizenship" onChange="questiondisplay(this[this.selectedIndex].id);priorCvgQuestion();">');
document.write(getCtyCitizenshipHTML());
document.write('             </select>	        </td>');
document.write('        </tr>');
document.write('        <tr id="row1">');
document.write('            <td  id="pad1">&nbsp;8. </td>');
document.write('            <td  id="pad2">Select the country/countries where coverage is required</td>');
document.write('            <td id="pad" colspan="8"><div id="q8"><select id="CountryforCoverage" onchange="arrivaldisplay(this);priorCvgQuestion();" name="CountryforCoverage">');
document.write('                    <option selected="selected" value="1">USA only</option>');
document.write('                     <option value="3">ALL nations including USA</option>');
document.write('                     <option value="4">ALL nations excluding USA</option>');
document.write('                   </select>');
document.write('                 </div></td>');
document.write('              </tr>');
document.write('              <tr id="row">');
document.write('                <td  id="pad1">&nbsp;9. </td>');
document.write('                <td id="pad2">Where is the mailing address');
document.write('                    <span class="smallFont">(Address to mail the insurance ID card and certificate)</span></td>');
document.write('                <td id="pad" colspan="8"><div id="q9c">');	
document.write('						<select name="MailingAddress" id="MailingAddress">');
document.write('                    		<option selected="selected" value="2">Outside-USA </option>');
document.write(                    			getUSStatesForCombo());
document.write('                		</select>	');			   
document.write('						   </div></td>');	
document.write('              </tr>');
document.write('              <tr id="row1">');	
document.write('                <td  id="pad1">&nbsp;10. </td>');	
document.write('                <td id="pad2">Where is the traveler/visitor&#39;s permanent home');
document.write('				<span class="smallFont">(Applicant&#39;s permanent home to which he/she has the intention of returning to.)</span></td>');	
document.write('                <td id="pad" colspan="8"><div id="q10c">');	
document.write('                	<select  name="Residence" id="Residence">');
document.write('                     <option selected="selected" value="2">Outside-USA </option>');
document.write(                   getUSStatesForCombo());
document.write('    							</select>');
document.write('							   </div></td>');	
document.write('              </tr>');
document.write('              <tr id="row">');
document.write('					<td  id="pad1"><div id="q11a">&nbsp;11. </div></td>');
document.write('					<td id="pad2"><div id="q11b">If the traveler is already in USA, how long has the traveler been in USA');
document.write('					<span class="smallFont">(Choose your latest entry to USA.)</span></div></td>');	
document.write('               		<td  colspan="8" id="pad"> <div id="q11c">');
document.write('                		<select name="USarrival" id="USarrival" onchange="priorCvgQuestion();">');
document.write(getUSArrivalHTML());
document.write('                		</select>');
document.write('                	</td>');
document.write('              </tr>');
document.write('	 <tr id="row1"> ');
document.write('            <td id="pad1"><div id="q12a"></div></td>');
document.write('            <td id="pad2"><div id="q12b"></div></td>');
document.write('            <td id="pad"><div id="q12c"></div></td>');		
document.write('	</tr>');
document.write('              </table>');
document.write('<table width="100%">');
document.write('    <tr>');
document.write('        <td height="10" colspan="3" align="center"> ');               
document.write('                <input type="button" value=" Get Quote! " name="quote" onMouseOver="this.className=\'submitbuttonon\'" onMouseOut="this.className=\'submitbutton\'" class="submitbutton" onClick="validate();" id="getquote_but"/>');
document.write('               <input name="resetquote" type="button" class="submitbutton" onClick="resetform();" onMouseOver="this.className=\'submitbuttonon\'" onMouseOut="this.className=\'submitbutton\'" value=" Reset Options" id="resetquote_but"/>');
document.write('         </td>');
document.write('	</tr>');
document.write('</table>');
document.write('</form>');