document.write('<form method="post" name="form1" class="quote-form" action="/visitor-medical-insurance-quotes.asp">');
document.write(' <fieldset>');
document.write(' <div class="row">');
document.write(' <label for="age">Traveler\'s Age</label>');
document.write(' <input name="Age" type="text" id="travelerage" onkeypress="return numbersonly(event);" maxlength="2" class="text" value="" />');
document.write('</div>');
document.write('<div class="row">');
document.write(' <label for="age2">');
document.write(' Spouse Age (if required)');
document.write(' </label>');
document.write(' <input type="text" name="spouseAge" onkeypress="return numbersonly(event);" maxlength="2" class="text" value="" />');
document.write(' </div>');
document.write(' <div class="row">');
document.write(' <label for="coverage">');
document.write(' Max Coverage');
document.write(' </label>');
document.write(' <select id="coverage" name="MaxPolicyLimit" title="select">');
document.write(' <option value="0-25000">$25,000 or less </option>');
document.write(' <option value="26000-60000" selected="selected">$50K</option>');
document.write(' <option value="76000-100000">$100K</option>');
document.write(' <option value="101000-499000">$101K to $499K</option>');
document.write(' <option value="500000">$500K</option>');
document.write(' <option value="1000000">$1,000K</option>');
document.write(' <option value="5000000">$5,000K</option>');
document.write(' <option value="8000000">$8,000K</option>');
document.write(' </select>');
document.write(' </div>');
document.write(' <div class="row">');
document.write(' <strong>Coverage Period</strong>');
document.write(' <div class="holder">');
document.write(' <div class="frame">');
document.write(' <label for="month">');
document.write(' Months');
document.write(' </label>');
document.write(' <input name="monthsOfCoverage" type="text" onkeypress="return numbersonly(event);" value="1" id="lab3" class="text small" title="Coverage Period Months"  />');
document.write(' </div>');
document.write(' <div class="frame alt-frame">');
document.write(' <label for="day">');
document.write(' Days');
document.write(' </label>');
document.write(' <input name="daysOfCoverage" type="text" onkeypress="return numbersonly(event);" value="0" id="lab4" class="text small" title="Coverage Period Days" />');
document.write(' </div>');
document.write(' </div>');
document.write(' </div>');
document.write(' <div class="row">');
document.write(' <strong>Citizenship</strong>');
document.write(' <div class="holder">');
document.write(' <input type="radio" name="CountryofCitizenship" value="2" checked="checked"  onclick="setCountryforCoverage(1);" id="lab5" class="radio" title="Non-US" />');
document.write(' <label for="lab5">');
document.write(' Non US');
document.write(' </label>');
document.write(' <input id="lab6" class="radio" type="radio" name="CountryofCitizenship" value="1"  onclick="setCountryforCoverage(4);" title="US" />');
document.write(' <label for="lab6">');
document.write(' US');
document.write(' </label>');
document.write(' </div>');
document.write(' </div>');
document.write(' <div class="row">');
document.write(' <input id="us" type="image" class="submit" alt="submit button" src="/images/btn-quote.gif"  onclick="return validatemini();" />');
document.write(' </div>');
document.write(' <div class="more" title="more options" onmouseover="setCursor(this, &#39;pointer&#39;);"  onmouseout="setCursor(this, &#39;auto&#39;);">');
document.write(' <a onclick="gomain();">More Options</a>');
document.write(' </div>');
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('</fieldset>');
document.write('</form>');