document.write('<form name="form1" class="container-form" method="post" action="/visitor-medical-insurance-quotes.asp">');
document.write('<fieldset>');
document.write('<div class="form-table-holder">');
document.write('<em class="arrow"></em>');
document.write('<table class="form-table">');
document.write('<tbody>');
document.write('<tr>');
document.write('<td class="number1">1.</td>');
document.write('<td class="label1"><label for="input1">Traveler/Visitor\'s Age</label></td>');
document.write('<td class="input1"><input onkeypress="return numbersonly(event);" onkeyup="priorCvgQuestion();" class="text" type="text" id="input1" value="" maxLength="2" size="2" name="Age" tabindex="1"/>');
document.write('				  <input type="hidden" name="affiliate" value="ivisi"></td>');
document.write('<td class="number2">2.</td>');
document.write('<td class="label2"><label for="input2">Spouse Age (if coverage is required)</label></td>');
document.write('<td class="input2"><input class="text" type="text" id="input2" value="" onkeypress="return numbersonly(event);" onkeyup="priorCvgQuestion();" maxLength="2" size="2" name="spouseAge" tabindex="2"/></td>');
document.write('</tr>');
document.write('<tr>');
document.write('<td class="number1 colored">3.</td>');
document.write('<td class="label1 colored">');
document.write('<label for="input3">Ages of children under 18 </label>');
document.write('<em>(child must be accompanied by parent)</em>');
document.write('</td>');
document.write('<td class="input1 colored">');
document.write('<div class="child-box">');
document.write('<input name="dependant0" class="text" title="child" id="dependant0" type="text" value="Child 1"  onkeypress="return numbersonly(event);" tabindex="3" onkeyup="validChildrenAge();" />');
document.write('<input name="dependant1" class="text" title="child" id="dependant1" type="text" value="Child 2" onkeypress="return numbersonly(event);" tabindex="4" onkeyup="validChildrenAge();" />');
document.write('<input name="dependant2" class="text" title="child" id="dependant2" type="text" value="Child 3"  onkeypress="return numbersonly(event);" tabindex="5" onkeyup="validChildrenAge();"/>');
document.write('<input name="dependant3" class="text" title="child" id="dependant3" type="text" value="Child 4"  onkeypress="return numbersonly(event);" tabindex="6" onkeyup="validChildrenAge();" />');
document.write('</div>');
document.write('<input name="NumberOfChildren" type="hidden" value="0"/>');
document.write('</td>');
document.write('<td class="number2 colored align-middle">4.</td>');
document.write('<td class="label2 colored"><label for="radio-box1">Citizenship of Visitor</label></td>');
document.write('<td class="input2 colored">');
document.write('<div class="radio-box"  onclick="questiondisplay(true);priorCvgQuestion();">');
document.write('<input type="text" id="radio-box1" />');
document.write('<input id="input4"  name="CountryofCitizenship" type="radio" class="radio" value="2" checked="checked"  tabindex="7" />');
document.write('<label for="input4">Non US</label>');
document.write('<input id="input5"  name="CountryofCitizenship"  type="radio" class="radio" value="1"  tabindex="8" />');
document.write('<label for="input5">US</label>');
document.write('</div>');
document.write('</td>');
document.write('</tr>');
document.write('<tr>');
document.write('<td class="number1">5.</td>');
document.write('<td class="label1">');
document.write('<label for="select2">Medical Coverage limit/max </label>');
document.write('<em>(max hospital, doctors, drugs etc)</em>');
document.write('</td>');
document.write('<td class="input1">');
document.write('<select class="price" id="select2" name="MaxPolicyLimit"  tabindex="9" >');
		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","$8,000,000");
document.write(getMaxPolLimitHTML(maxpolLim, mpl, "26000-60000"));   
document.write('</select>');
document.write('</td>');
document.write('<td class="number2">6.</td>');
document.write('<td class="label2">');
document.write('<label for="select3">Deductible Range :</label>');
document.write('<em>(initial amt. you pay in the event of claim)</em>');
document.write('</td>');
document.write('<td class="input2">');
document.write('<select class="price2" id="select3" name="Deductible" tabindex="10" >');
var vdeductible=new Array("0","50-100", "101-250", "500", "1000", "2500", "5000","10000", "25000");
var vdbl = new Array("US$ 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>');
document.write('</td>');
document.write('</tr>');
document.write('<tr>');
document.write('<td class="number1 colored"><span>7.</span></td>');
document.write('<td class="label1 colored">');
document.write('<label class="coverage" for="select4">Coverage</label>');
document.write('<div class="label-box">');
document.write('<span>From:</span>');
document.write('<span>To:</span>');
document.write('</div>');
document.write('</td>');
document.write('<td class="input1 colored">');
document.write('<div class="select-box">');
document.write('<select class="month1" id="select4" onchange="setperiods();" name="DepartureMonth" tabindex="11" >');
document.write(getsetMonthHTML(stref.getMonth()+1));
document.write('</select>');
document.write('<select class="date1" title="date" onchange="setperiods();" name="DepartureDay" tabindex="12" >');
document.write(getsetDayHTML(stref.getDate()));
document.write('</select>');
document.write('<select class="date2" title="date"  onchange="setperiods();" name="DepartureYear" tabindex="13" >');
document.write(getsetYearHTML(stref.getFullYear()));
document.write('</select>');
document.write('</div>');
document.write('<div class="select-box">');
document.write('<select class="month1" title="date" onchange="setperiods();" name="ReturnMonth" tabindex="14" >');
document.write(getsetMonthHTML(temp.getMonth()+1));
document.write('</select>');
document.write('<select class="date1" title="date" onchange="setperiods();" name="ReturnDay" tabindex="15" >');
document.write(getsetDayHTML(temp.getDate()));
document.write('</select>');
document.write('<select class="date2" title="date" onchange="setperiods();" name="ReturnYear" tabindex="16" >');
document.write(getsetYearHTML(temp.getFullYear()));
document.write('</select>');
document.write('				<input name="monthsOfCoverage" readonly="true" type="hidden" size="1" value="1" maxlength="2">');
document.write('				<input name="daysOfCoverage" readonly="true" type="hidden" size="1" value="0" maxlength="2">');
document.write('</div>');
document.write('</td>');
document.write('<td class="number2 colored align-middle">8.</td>');
document.write('<td class="label2 colored"><label for="select5">Country/Countries for Coverage</label></td>');
document.write('<td class="input2 colored">');
document.write('<select onchange="arrivaldisplay(this);priorCvgQuestion();" size="1" name="CountryforCoverage" class="price2" id="select5"    tabindex="17" >');
document.write('                    <option selected="selected" value="1">USA only</option>');
document.write('                     <option value="3">ALL nations incl. US</option>');
document.write('                     <option value="4">ALL nations excl. US</option>');
document.write('</select>');
document.write('</td>');
document.write('</tr>');
document.write('<tr>');
document.write('<td class="number1"><span class="number-9">9.</strong></td>');
document.write('<td class="label1"><label for="select6">Mailing address to send ID card </label></td>');
document.write('<td class="input1">');
document.write('<select name="MailingAddress" class="price" id="select6" tabindex="18" >');
document.write('<option selected="selected" value="2">Outside USA</option>');
document.write(getUSStatesForCombo());
document.write('</select>');
document.write('</td>');
document.write('<td class="number2">10.</td>');
document.write('<td class="label2"><label for="select7">Permanent home that visitor <br/> intends to return</label></td>');
document.write('<td class="input2">');
document.write('<select class="price2" id="select7" name="Residence" tabindex="19" >');
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>');
document.write('<td class="number1 colored"><div id="q11a">11.</div></td>');
document.write('<td class="label1 colored"><div id="q11b"><label for="select8">If visitor already in USA, <br /> how long has visitor been in USA</label></div></td>');
document.write('<td class="input1 colored"><div id="q11c">');
document.write('<select class="price" id="q11c" name="USarrival" onchange="priorCvgQuestion();" tabindex="20" >');
document.write(getUSArrivalHTML());
document.write('</select></div>');
document.write('</td>');
document.write('<td class="number2 colored" ><div id="q12a" class="hide">12.</div></td>');
document.write('<td class="label2 colored" ><div id="q12b" class="hide"><label for="select9">During the last 30 days were all<br/>applicants covered by travel<br/>insurance? </label></div></td>');
document.write('<td class="input2 colored" >');
document.write('<div class="hide" id="q12c"><div class="radio-box radio-box1">');
document.write('<input type="text" id="select9" />');
document.write('<input id="radio1" type="radio" class="radio" name="PriorCoverage" checked="checked" value="1" tabindex="21"  />');
document.write('<label for="radio1">Yes</label>');
document.write('<input id="radio2" type="radio" class="radio" name="PriorCoverage" value="0" tabindex="22" />');
document.write('<label for="radio2">No</label>');
document.write('</div></div>');
document.write('</td>');
document.write('</tr>');
document.write('</tbody>');
document.write('</table>');
document.write('</div>');
document.write('<input id="us" type="image" class="submit" alt="submit button" src="/images/btn-quote.gif"  tabindex="23"  onclick="return validate();"/>');
document.write('<div class="reset-holder">');
document.write('<input type="reset" value="Reset Option" class="reset" onClick="resetform();"  tabindex="24"  />');
document.write('</div>');
document.write('</fieldset>');
document.write('</form>');