document.write('<form name="form1" onsubmit="validate();" method="post" action="/results/shortterm/" >');
document.write("<table width='100%' border='0' cellpadding='0' cellspacing='0'  class='quote'>");
document.write("<tbody>");
document.write(" <tr valign='top' >");
document.write("    <td width='3%' class='formbg'>&nbsp;1.</td>");
document.write("    <td width='50%' class='formbg'>Enter the age of the applicant</td>");
document.write("    <td width=12%' colspan='2' class='formbg'><input size='2' name='Age' onKeyPress='return numbersonly(event);' maxlength='2' >");
document.write("		<input name='affiliate' type='hidden' value='eshortterm'></td>");
document.write("   <td width=' 35%' colspan='6' class='formbg' >");
document.write('				    <select name="pgender" size="1" onChange="FixGender(this[this.selectedIndex].value,&#39;p&#39;);">');
document.write('                 		<option selected="selected" value="M">Male</option>');
document.write('                  		<option value="F">Female</option>');
document.write('                	</select></td>');
document.write(" </tr>");
document.write("<tr valign='top'>");
document.write("    <td>&nbsp;2.</td>");
document.write("    <td>Enter age of the applicant&#39;s spouse if coverage for spouse is required</td>");
document.write("    <td colspan='2'><input size='2' name='spouseAge' onKeyPress='return numbersonly(event);' maxlength='2'></td>");
document.write("    <td colspan='6'><select name='sgender' size='1' onChange='FixGender(this[this.selectedIndex].value,&#39;p&#39;);'>");
document.write('                 		<option value="M">Male</option>');
document.write('                  		<option selected="selected" value="F">Female</option>');
document.write('                	</select> </td>');
document.write(" </tr>");
document.write("<tr valign='top'>");
document.write("    <td height='28' valign='top' class='formbg'>&nbsp;3. </td>");
document.write("    <td class='formbg'>Enter number &amp; ages of dependents under 18 requiring coverage");
document.write("	<div class='formsmallfont'>Child less than 18 years and accompanied by a parent or guardian.</div>");
document.write("    </td>");
document.write("    <td width='9%' height='36' class='formbg'>");
document.write("         <div><select name='NumberOfChildren' size='1' onchange='showtextbox(this.selectedIndex);'>");
document.write(getNoChildrenHTML()); 
document.write("         </select></div>");
document.write("    </td>");
document.write(getDependantCellHTML());
document.write("</tr>");
document.write("<tr valign='top'>");
document.write("    <td>&nbsp;4. </td>");
document.write("    <td >Select the deductible amount.");
document.write("         <div class='formsmallfont'>The initial amount that you are responsible for before the insurance pays for medical expense.</div></td>");
document.write("      <td colspan='8'><select name='Deductible' size='1'>");
var vdeductible=new Array("0","250", "500", "1000", "1500", "2500", "3500", "5000", "7500", "10000");
var vdbl = new Array("US$ 0","US$ 250","US$ 500","US$ 1000 ","US$ 1500 ","US$ 2500 ","US$ 3500 ","US$ 5000 ", "US$ 7500 ", "US$ 10000 ");
document.write(getDeductibleHTML(vdeductible, vdbl, "1000"));		
document.write("                  </select></td>");
document.write("</tr>");
document.write(" <tr valign='top'>");
document.write("     <td class='formbg'>&nbsp;5.</td>");
document.write("     <td class='formbg'>How would you like to pay your premiums?</td>");
document.write("      <td colspan='8' class='formbg'><select onchange='questiondisplay4(this[this.selectedIndex].value);' name='paymentType' size='1'>");
var paymentType = new Array("Single payment","Monthly (Up to 6 Months)", "Monthly (Up to 12 Months)");
				for(var i=1; i <4; i++)
				{								
					if (i == 1)
						document.write('<option selected value="' +  i +'">' + paymentType[i-1] + '</option>');
					else
						document.write('<option value="' + i +'">' + paymentType[i-1] + '</option>');	
				}                                               
document.write('            </select></td>');
document.write("</tr>");
document.write('   <tr vAlign="top"> ');
document.write('            <td width="3%" >&nbsp;6.</td>');
document.write('            <td width="50%" >Select the dates for coverage </td>');
document.write('            <td> <div>Start Date:&nbsp;</div><div id="frmEndDate">End Date:&nbsp;&nbsp;</div></td>');
document.write('            <td colSpan="8"> <div>');
document.write('                 <select onchange="setshortperiods();" size="1" name="DepartureMonth">');
document.write(getMonthHTML());
document.write('                 </select>');
document.write('                 <select onchange="setshortperiods();" size="1" name="DepartureDay">');
document.write(getDayHTML());
document.write('				 </select>');
document.write('                 <select onchange="setshortperiods();" size="1" name="DepartureYear">');
document.write(getYearHTML());
document.write('                 </select>');
document.write('	            </div><div> <span id="frmReturnDate">');
document.write('                  <select onchange="setperiods();" size="1" name="ReturnMonth">');
document.write(getMonthHTML());
document.write('				  </select>');
document.write('                  <select onchange="setperiods();" size="1" name="ReturnDay">');
document.write(getDayHTML());
document.write('				</select>');
document.write('                 <select onchange="setperiods();" size="1" name="ReturnYear">');
document.write(getYearHTML());
document.write('                 </select>&nbsp;&nbsp; </span> ');
document.write('			<span id="frmMonsDays">	<input name="monthsOfCoverage" readonly="true" size="1" value="1" maxlength="2">months');
document.write('				<input name="daysOfCoverage" readonly="true" size="1" value="0" maxlength="2"> days</span></div>');
document.write('           </td>');
document.write('    </tr>');
document.write(" <tr valign='top'>");
document.write("     <td class='formbg'>&nbsp;7.</td>");
document.write("     <td class='formbg'>Select the co-insurance amount policy should pay</td>");
document.write("      <td colspan='8' class='formbg'><select name='coinsurance' size='1'>");
						var vcoinsurance=new Array("5050","8020", "0100");
						var vcoin = new Array("50%","80%", "100%");
document.write(getcoinsuranceHTML(vcoinsurance, vcoin, "8020"));                                              
document.write('            </select></td>');
document.write("</tr>");
document.write('	 <tr vAlign="top"> ');
document.write('            <td width="3%" >&nbsp;<span >8.</span></td>');
document.write('            <td width="49%" ><span >');
document.write('				Where does the applicant currently reside?  </span> ');
document.write('				   <span >  Enter the Zip Code of your residing location </span></td>');
document.write('            <td colspan="3"> <div id="q10c">');
document.write('				<select name="residence" size="1">');
document.write(' <option value="" selected="selected">Select State </option>');
document.write( getUSStatesForCombo());
//document.write(' <option value="CO">CO Colorado</option>');
//document.write(' <option value="TX">TX Texas</option>');
//document.write(' <option value="VA">VA Virginia</option>');
document.write('				</select>');												
document.write('            </div></td>');
document.write('				<td ><span> ZipCode&nbsp;</span></td>');
document.write('          <td><input onkeypress="return numbersonly(event);" maxLength="5" size="5" name="zipcode"></td>');
document.write('	</tr>');
document.write("</tbody></table>");
document.write("<br />");
document.write(getCompareButtonRow());
document.write("</form>");