document.write('<form name="form1" onsubmit="validate();" method="post" action="/results/global/">');
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=12%' colspan='2' class='formbg'><input size='2' name='Age' onKeyPress='return numbersonly(event);' maxlength='2' >");
document.write("		<input name='affiliate' type='hidden' value='zinternational'></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 traveler&#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","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$ 10,000","US$ 25,000");
document.write(getDeductibleHTML(vdeductible, vdbl, "500"));		
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 name='paymentType' size='1'>");
var paymentType = new Array("Annually (1 Year)","Semi Annually (6 Months)","Quarterly (3 Months)", "Monthly (1 Month)");
				for(var i=1; i <5; i++)
				{								
					if (i == 1)
						document.write('<option selected value="' +  i +'">' + paymentType[i-1] + '</option>');
					else
						document.write('<option value="' + i +'">US$ ' + paymentType[i-1] + '</option>');	
				}                                               
document.write('            </select></td>');
document.write("</tr>");
document.write("<tr valign='top'>");
document.write("      <td>&nbsp;6. </td>");
document.write("      <td>Select the visitor/traveler&#39;s country of citizenship	</td>");
document.write("      <td colspan='8'><select name='CountryofCitizenship' size='1' onChange='questiondisplay(this[this.selectedIndex].id);'>");
document.write('                   <option id="NONUSA" value="2">Non-USA</option>');
document.write('                   <option selected="selected" id="USA" value="1">USA</option>');
document.write("                </select>	        </td>");
document.write(" </tr>");
document.write("    <td valign='top' class='formbg' >&nbsp;7. </td>");
document.write("    <td class='formbg' valign='top' >Select the country/countries where coverage is required</td>");
document.write("     <td class='formbg' colspan='8'><div id='q8'>");
		var ctyCoverage = new Array("Worldwide including USA (Excluding Canada)", "Worldwide including Canada (excluding USA)",
							 "Worldwide including USA & Canada", "Worldwide excluding USA & Canada");
		for (var i=1; i<5; i++)
		{
			if (i ==1)						
				document.write(' <input name="CountryforCoverage" type="radio" checked="checked" value="' + i +'">' + ctyCoverage[i-1] + '<br>');
			else
			
				document.write(' <input name="CountryforCoverage" type="radio" value="' + i +'">' + ctyCoverage[i-1] + '<br>');
		}
document.write("    </div></td>");
document.write("</tr>");
document.write("<tr valign='top'>");
document.write("    <td>&nbsp;8. </td>");
document.write("     <td>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'><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>");
document.write("    <td valign='top' class='formbg' >&nbsp;9. ");
document.write("    <td class='formbg' valign='top' >Where is the traveler/visitor's permanent home");
document.write("            <div class='formsmallfont'>Applicant's fixed/permanent home to which he/she has the intention of returning to.</div></td>");
document.write("      <td colspan='8' class='formbg'><select name='Residence' size='1'  onChange='showhideArea(this[this.selectedIndex].value);'>");
document.write("                     <option selected='selected' value='2'>Outside-USA </option>");
document.write(          getUSStatesForCombo());
document.write("    	</select><div id='q10d'>&#160;</div></td>");	
document.write(" </tr>");
document.write("</tbody></table>");
document.write("<br />");
document.write(getCompareButtonRow());
document.write("</form>");