document.write('		<form method="post" name="tripminiform" action="/results/trip/" onsubmit="return tripvalidate();">');
document.write('			<table  id="tripquote" border="0" cellpadding="0" cellspacing="0" width="100%" height="280">');
document.write('	        <tbody>');
document.write('	        <tr>');
document.write('	              <td height="25">Residence</td>');
document.write('			<td height="25" colspan="2"><select name="CountryOfResidence" size="1">');
document.write('							<option value="" selected>Select Residence</option>');
document.write('							<option value="2">Non-USA</option>');
document.write(         getUSStatesForCombo());
document.write('	                     </select> ');
document.write('					</td>');
document.write('	          </tr>');
document.write('	          <tr> ');
document.write('	                <td height="25">Applicant</td>');
document.write('	                <td nowrap>Age&nbsp;&nbsp;<input type="text" size="2" name="Age1" id="Age1" onkeypress="return numbersonly(event);" maxlength="2" onChange="this.value=extractNumeric(this.value)"></td>');
document.write('	                <td nowrap>Age&nbsp;&nbsp;<input type="text" size="2" name="Age2" id="Age2" onkeypress="return numbersonly(event);" maxlength="2" onChange="this.value=extractNumeric(this.value)"></td>');
document.write('	          </tr>');
document.write('	          <tr>');
document.write('			    	<td height="25" >Trip</td>');
document.write('			       <td nowrap>Cost <input name="TripCost1" type="text" id="TripCost1" onkeypress="return numbersonly(event);" size="4" onKeyPress="return numbersonly(event);" onChange="this.value=extractNumeric(this.value)"></td>');
document.write('			       <td nowrap>Cost <input name="TripCost2" type="text" id="TripCost2" onkeypress="return numbersonly(event);" size="4" onKeyPress="return numbersonly(event);" onChange="this.value=extractNumeric(this.value)"></td>');
document.write('			  </tr>');
document.write('              <tr> ');
document.write('                    <td height="25">Coverage</td>');
document.write('                    <td height="25" colspan="2"> ');
document.write(' 						<input type="text" name="TripLength" style="width: 20px;" value="8" onkeypress="return numbersonly(event);" maxlength="3" type="text">&nbsp;days');
document.write('					</td>');
document.write('              </tr>');
//document.write('	        <tr> ');
//document.write('				<td height="1" colspan="5" valign="top" >');
document.write('					<input type="hidden" name="Age3" id="Age3"/>');
document.write('					<input type="hidden" name="Age4" id="Age4"/>');
document.write('					<input type="hidden" name="Age5" id="Age5"/>');
document.write('					<input type="hidden" name="TripCost3" id="TripCost3"/>');
document.write('					<input type="hidden" name="TripCost4" id="TripCost4"/>');
document.write('					<input type="hidden" name="TripCost5" id="TripCost5"/>');
document.write('					<input type="hidden" name="affiliate" value="zinternational">');
document.write('					<input type="hidden" name="ra"/>');
document.write('					<input type="hidden" name="ta1"/>');
document.write('					<input type="hidden" name="ta2"/>');
document.write('					<input type="hidden" name="tc1"/>');
document.write('					<input type="hidden" name="tc2"/>');
document.write('					<input type="hidden" name="tl"/>');
//document.write('				</td>');
//document.write('	        </tr>');

document.write('              <tr> ');
document.write('                   <td height="35" colspan="3"> ');
document.write('                   <div align="center"><br>&nbsp;<br>');
document.write('			<input class="formbuttonminitrip" onmouseover="this.className=&#39;formbuttonsubmitminitrip&#39;" onmouseout="this.className=&#39;formbuttonminitrip&#39;" value=" Get Quote! " name="Submit"  type="submit"/> ');
document.write('			<input class="formbuttonminitrip" onmouseover="this.className=&#39;formbuttonsubmitminitrip&#39;" onmouseout="this.className=&#39;formbuttonminitrip&#39;" value="More Options" name="quote2" type="button" onClick="gomaintrip();"/>');
document.write('			</div> </td>');
document.write('            </tr>');
document.write('           </tbody>');
document.write('           </table>');
document.write('		</form>');