document.write('<form name="form1" onsubmit="validate();" method="post" action="/results/visitor/">');
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 traveler or visitor</td>");
document.write("    <td width=47%' colspan='8' 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(" </tr>");
document.write("<tr valign='top'>");
document.write("    <td>&nbsp;2.</td>");
document.write("    <td>Enter age of the traveler&#39;s spouse if coverage for spouse is required</td>");
document.write("    <td colspan='8'><input size='2' name='spouseAge' onKeyPress='return numbersonly(event);' maxlength='2'></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 coverage limit for medical expenses");
document.write("         <div class='formsmallfont'>Maximum eligible medical expenses that the plan will cover.</div></td>");
document.write("    <td colspan='8' ><select name='MaxPolicyLimit' size='1'>");
	var maxpolLim = new Array("0-25000","26000-60000", "61000-100000", "101000-499000", "500000","1000000");
	var mpl = new Array("$25,000 or less","$26,000 to $60,000","$61,000 to $100,000","$101,000 to $499,000","$500,000","$1,000,000");
document.write(getMaxPolLimitHTML(maxpolLim, mpl, "26000-60000"));
document.write("                </select></td>");
document.write("</tr>");
document.write(" <tr valign='top' class='formbg'>");
document.write("     <td class='formbg'>&nbsp;5.</td>");
document.write("     <td class='formbg'>Select the deductible amount");
document.write("	<div class='formsmallfont'>The initial amount that you are responsible for before the insurance pays for medical expense.</div></td>");
document.write("      <td colspan='8' class='formbg'><select name='Deductible' size='1'>");
var vdeductible=new Array("0","50-100", "101-250", "500", "1000", "2500", "5000","10000", "25000");
var vdbl = new Array("US$ 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 valign='top'>");
document.write("      <td>&nbsp;6. </td>");
document.write("    <td >Select the dates for coverage </td>");
document.write("    <td ><div>Start Date:&#160;</div><div >End Date:&#160;&#160;</div></td>");
document.write("    <td colspan='6'><div class='formsmallfont'><select name='DepartureMonth' size='1' onChange='setperiods();'>");
document.write(getMonthHTML());
document.write("                </select>");
document.write("                <select name='DepartureDay' size='1' onChange='setperiods();'>");
document.write(getDayHTML());
document.write("                </select>");
document.write("                <select name='DepartureYear' size='1' onChange='setperiods();'>");
document.write(getYearHTML());
document.write("                </select></div>");
document.write("                 <div><select name='ReturnMonth' size='1' onChange='setperiods();'>");
document.write(getMonthHTML());
document.write("                  </select>");
document.write("                  <select name='ReturnDay' size='1' onChange='setperiods();'>");
document.write(getDayHTML());
document.write("                  </select>");
document.write("                  <select name='ReturnYear' size='1' onChange='setperiods();'>");
document.write(getYearHTML());
document.write("                  </select>");
document.write("&#160;&#160;");
document.write("<input name='monthsOfCoverage' readonly='true' size='1' value='1' maxlength='2' >months &#160;");
document.write("<input name='daysOfCoverage' readonly='true' size='1' value='0' maxlength='2' > days</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 visitor/traveler&#39;s country of citizenship	</td>");
document.write("      <td colspan='8' class='formbg'><select name='CountryofCitizenship' size='1' onChange='questiondisplay(this[this.selectedIndex].id);'>");
document.write(getCtyCitizenshipHTML());
document.write("                </select>	        </td>");
document.write(" </tr>");
document.write(" <tr>");
document.write("    <td>&nbsp;8. </td>");
document.write("    <td valign='top' >Select the country/countries where coverage is required</td>");
document.write("     <td colspan='8'><div id='q8'><select name='CountryforCoverage' size='1'>");
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 valign='top'>");
document.write("    <td  class='formbg'>&nbsp;9. </td>");
document.write("     <td class='formbg'>Where is the mailing address");
document.write("            <div class='formsmallfont'>Address to mail the insurance ID card and certificate</div></td>");
document.write("      <td colspan='8' class='formbg'><div id='q9c'>");
document.write("              <select name='MailingAddress' size='1'>");
document.write("                    <option selected='selected' value='2'>Outside-USA </option>");
document.write(                    getUSStatesForCombo());
document.write("               </select></div></td>");
document.write("</tr>");
document.write("<tr valign='top'>");
document.write("      <td >10.</td>");
document.write("    <td>Where is the traveler/visitor&#39;s permanent home");
document.write("        <div class='formsmallfont'>Applicant&#39;s fixed/permanent home to which he/she has the intention of returning to.</div></td>");
document.write("    <td colspan='8'><select name='Residence' size='1' >");
document.write("                     <option selected='selected' value='2'>Outside-USA </option>");
document.write(          getUSStatesForCombo());
document.write("    	</select></td>");	
document.write(" </tr>");
document.write("<tr valign='top'>");
document.write("    <td  class='formbg' id='q11a'>11. </td>");
document.write("       <td id='q11b'  class='formbg'>If traveler already in USA, how   long has the traveler been in USA");
document.write("		<div class='formsmallfont'>Choose your latest entry to USA.</div></td>");
document.write("       <td colspan='8' id='q11c' class='formbg'>");
document.write("             <select name='USarrival' size='1'>");
document.write('                  			<option selected="selected" value="5">Not in USA yet</option>');
document.write('                    		<option value="0">Most recent US entry is within last 3 months</option>');
document.write('                    		<option value="1">Most recent US entry is within last 12 months</option>');
document.write('                    		<option value="2">Most recent US entry is within last 18 months</option>');
document.write('                    		<option value="3">Most recent US entry is within last 24 months</option>');
document.write('                    		<option value="4">Most recent US entry is more than 2 years ago</option>');
document.write("</tr></tbody></table>");
document.write("</br>");
document.write(getCompareButtonRow());
document.write("</form>");