document.write('   	<form method="post" name="form1" action="/exchange-visitor-insurance-concise.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">'); document.write(displayname); document.write('&#39;s age</td>');
document.write('			      <td colspan="8" id="pad">');
document.write('				   		<input size="2" name="Age" id="Age" onKeyPress="return numbersonly(event);" maxlength="2" >');
document.write('				   		<input type="hidden" name="affiliate" value="ivisi">');
document.write('				  </td>');
document.write('			</tr>');
document.write('			<tr id="row1">');
document.write('			      <td id="pad1">&nbsp;2.</td>');
document.write('                  <td id="pad2">'); document.write(displayname); document.write('&#39;s spouse age<span class="smallFont">&nbsp;(if coverage for spouse is required.)</span></td>');
document.write('			      <td colspan="8" id="pad">');
document.write('						<input size="2" name="spouseAge" id="spouseAge" onKeyPress="return numbersonly(event);" maxlength="2" >');
document.write('				  </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 medical maximum coverage amount');
document.write('            	   <span class="smallFont">&nbsp;(Maximum eligible medical expenses that the plan will cover.)</span></td>');
document.write('				  <td colspan="8" id="pad">');
document.write ('						<select name="MaxPolicyLimit" id="MaxPolicyLimit" onChange="alterDeductible(this.value);">');
			var maxpolLim = new Array("50000","200000-300000", "300001-500000","500001-1000000");
			var mpl = new Array("$50,000","$200,000 to $300,000","$300,001 to $500,000","$500,001 to $1,000,000");
document.write(getMaxPolLimitHTML(maxpolLim, mpl, "200000-300000"));						
document.write('                		</select>');
document.write('				  </td>');
document.write('			  </tr>');
document.write('			  <tr id="row">');
document.write('			     <td id="pad1">&nbsp;5.</td>');
document.write('                  <td id="pad2">Select the deductible amount');
document.write('                      <span class="smallFont">&nbsp;(The initial amount that you are responsible for before the insurance pays for medical expense.)</span></td>');
document.write('			      <td colspan="8" id="pad">');
document.write('						<select name="Deductible" size="1" id="Deductible" >');
			var vdeductible=new Array("0","50-100","101-250", "500", "1000", "2500");
			var vdbl = new Array("US$ 0","US$ 50 to 100","US$ 101 to 250","US$ 500","US$ 1000","US$ 2500 ");
document.write(getDeductibleHTML(vdeductible, vdbl, "50-100"));
document.write('                   </select>');
document.write('				</td>');
document.write('			  </tr>');
document.write('			  <tr id="row1">');
document.write('				   <td id="pad11">&nbsp;6. </td>');
document.write('                   <td id="pad22">Select the coverage time period</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>');
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">Where is the mailing address<span class="smallFont">&nbsp;(Address to mail the insurance ID card and certificate.)</span></td>');
document.write('                  <td colspan="8" id="pad"><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></div>');
document.write('					</td>');
document.write('              </tr>');
document.write('             <tr id="row1">');
document.write('                <td  id="pad1">&nbsp;8. </td>');
document.write('                <td id="pad2">Where is the '); document.write(displayname); document.write('&#39;s permanent home');
document.write('                <span class="smallFont">&nbsp;(Applicant&#39;s permanent home to which he/she has the intention of returning to.)</span></td>');
document.write('                <td colspan="8" id="pad">');
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('                </td>');
document.write('           </tr>');
document.write('           <tr id="row">');
document.write('                 <td  id="pad1">&nbsp;9.</td>');
document.write('                 <td id="pad2">Are you engaged in international education or research or cultural exchange program</td>');
document.write('                 <td colspan="8" id="pad">');
document.write('					<select name="Research" id="Research">');
document.write('						<option selected="selected" value="1">YES</option>');
document.write('						<option value="0">NO</option>');
document.write('					</select>');
document.write('                </td>');
document.write('          </tr>');
document.write('           <tr id="row1">');
document.write('                 <td  id="pad1">10.</td>');
document.write('                 <td id="pad2">Select the location of the ');document.write(displayname); document.write('&#39;s school/univ.</td>');
document.write('                 <td colspan="8" id="pad">');
document.write('					<select name="SchoolState" id="SchoolState">');
document.write( getUSStatesForCombo());
document.write('					</select>');
document.write('                </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=&#39;submitbuttonon&#39;" onMouseOut="this.className=&#39;submitbutton&#39;" class="submitbutton" onClick="validate();" id="getquote_but"/>');
document.write('               <input name="resetquote" type="button" class="submitbutton" onClick="resetform();" onMouseOver="this.className=&#39;submitbuttonon&#39;" onMouseOut="this.className=&#39;submitbutton&#39;" value=" Reset Options" id="resetquote_but"/>');
document.write('         </td>');
document.write('	</tr>');
document.write('</table>');
document.write('</form>');