document.write('<form name="form1" onSubmit="validate();" action="concise.asp" method="post">');
document.write('<table align="center" class="boxclass" cellpadding="0" cellspacing="0" border="1" width="100%">');
document.write('    <tr vAlign="top" bgColor="#f0f8ff"> ');
document.write('          <td width="3%" >&nbsp;1.</td>');
document.write('          <td width="54%">');
document.write('				Visitor&#39;s age</td>');
document.write('          <td colSpan="7">');
document.write('                 <input onkeypress="return numbersonly(event);" maxLength="2" size="2" name="Age">'); 
document.write('				  <input type="hidden" value="schengen" name="affiliate"></td>');
document.write('    </tr>');
document.write('    <tr vAlign="top"> ');
document.write('          <td >&nbsp;2.</td>');
document.write('          <td >Spouse&#39;s age</td>');
document.write('          <td colSpan="7"><input onkeypress="return numbersonly(event);" maxLength="2" size="2" name="spouseAge"></td>');
document.write('    </tr>');
document.write('    <tr vAlign="top" bgcolor="#f0f8ff"> ');
document.write('           <td height="28" width="3%">&nbsp;3.</td>');
document.write('           <td width="54%" >');
document.write('               Enter number &amp; ages of dependents under 18 requiring coverage '); 
document.write('	            <div  class="formsmallfont" style="PADDING-TOP: 2px">');
document.write('					Child less than 18 years and accompanied by a parent or guardian.</div></td>');
document.write('           <td width="6%" height="36" > <div> ');
document.write('				<select onchange="showtextbox(this.selectedIndex);" size="1" name="NumberOfChildren">');
document.write(getNoChildrenHTML());
document.write('				</select>');
document.write('           </div></td>');
document.write(getDependantCellHTML());
document.write('	</tr>');
document.write('   <tr vAlign="top"> ');
document.write('            <td width="3%">&nbsp;4.</td>');
document.write('            <td width="49%">');
document.write('					Select the coverage limit for medical expenses ');
document.write('                    <div style="PADDING-TOP: 2px" class="formsmallfont">');
document.write('					  Maximum eligible medical expenses that the plan will cover.</div></td>');
document.write('            <td colSpan="8"><select size="1" name="MaxPolicyLimit">');
	var maxpolLim = new Array("50000","100000", "250000", "500000", "1000000");
	var mpl = new Array("$50,000","$100,000","$250,000","$500,000","$1,000,000");
document.write(getMaxPolLimitHTML(maxpolLim, mpl,"50000"));                                                
document.write('            </select></td>');
document.write('   </tr>');
document.write('   <tr vAlign="top" bgColor="#f0f8ff" > ');
document.write('			<td width="3%" >&nbsp;5.</td>');
document.write('			<td width="49%" >');
document.write('				Select the deductible amount'); 
document.write('                <div class="formsmallfont" style="PADDING-TOP: 2px">');
document.write('					The initial amount that you are responsible for before the insurance pays for medical expense.');
document.write('			</div></td>');
document.write('            <td colSpan="8" >');
document.write('                  <select size="1" name="Deductible">');
var vdeductible=new Array("0","50-100", "101-250", "500", "1000", "2500");
var vdbl = new Array("US$ 0","US$ 50 to 100","US$ 101 to 250","US$ 500","US$ 1000 ","US$ 2500 ");
document.write(getDeductibleHTML(vdeductible, vdbl, "101-250"));
document.write('                  </select></td>');
document.write('   </tr>');
document.write('    <tr vAlign="top" > ');
document.write('           <td width="3%">&nbsp;6. </td>');
document.write('           <td width="49%">');
document.write('				Select the coverage time period </td>');
document.write('           <td colSpan="8"><div>');
document.write('                     <select name="DepartureMonth" size="1" onChange="setperiods(document.form1);">');
document.write(getMonthHTML());
document.write('                      </select>');
document.write('                      <select name="DepartureDay" size="1" onChange="setperiods(document.form1);">');
document.write(getDayHTML());																							  
document.write('                    	</select>');
document.write('                     	<select name="DepartureYear" size="1" onChange="setperiods(document.form1);">');
document.write(getYearHTML());
document.write('                      </select></div>');
document.write('                    <select name="ReturnMonth" size="1" onChange="setperiods(document.form1);">');
document.write(getMonthHTML());
document.write('                     </select>');
document.write('                     <select name="ReturnDay" size="1" onChange="setperiods(document.form1);">');
document.write(getDayHTML());
document.write('                     </select>');
document.write('                     <select name="ReturnYear" size="1" onChange="setperiods(document.form1);">');
document.write(getYearHTML());
document.write('                     </select>');
document.write('                     <input type="text" name="monthsOfCoverage" readonly="true" size="1">months');
document.write('                     <input type="text" name="daysOfCoverage" readonly="true" size="1">days');
document.write('            </td>');
document.write('    </tr>');
document.write('    <tr vAlign=top bgcolor="#f0f8ff"> ');
document.write('          <td width="3%" >&nbsp;7.</td>');
document.write('          <td width="50%" >');
document.write('				Select the visitor/traveler&#39;s country of citizenship</td>');
document.write('          <td colSpan=8 ><select name="CountryofCitizenship" size="1">');
document.write(getCtyCitizenshipHTML()); 
document.write('                   </select></td>');
document.write('    </tr>');
document.write('	<tr vAlign="top"> ');
document.write('            <td width="3%">&nbsp;8.</td>');
document.write('            <td width="49%">');
document.write('				Where are you using this website from?</td>');
document.write('            <td colSpan="8">');
document.write('				<input type="radio" name="Location" value="NY">New York &nbsp&nbsp;');
document.write('				<input type="radio" name="Location" value="others" checked="checked">Others &nbsp&nbsp;');
document.write('             </td>');
document.write('	 </tr>');

document.write('	<tr vAlign="top" bgcolor="#f0f8ff"> ');
document.write('            <td width="3%" >&nbsp;9.</td>');
document.write('            <td width="49%" >');
document.write('				Where is the visitor/traveler&#39;s permanent home?</td>');
document.write('            <td colSpan="8">');
document.write('				<select size="1" name="Residence">');
document.write('                     <option selected value="2">Outside-USA </option>');
document.write(getUSStatesForCombo());
document.write('                </select> </td>');
document.write('	 </tr>');
document.write('    <tr vAlign=top> ');
document.write('          <td width="3%">&nbsp;10.</td>');
document.write('          <td width="50%">');
document.write('				What is the mailing address?</td>');
document.write('          <td colSpan="8"><select name="MailingAddress" size="1">');
document.write('                     <option selected value="2">Outside-USA </option>');
document.write(getUSStatesForCombo()); 
document.write('                   </select></td>');
document.write('    </tr>');
document.write('	<tr vAlign="top" bgcolor="#f0f8ff"> ');
document.write('            <td width="3%" >11.</td>');
document.write('            <td width="49%" >');
document.write('				Select the country/countries you need coverage?</td>');
document.write('            <td colSpan="8" >');
document.write('				<select size="1" name="CountryforCoverage">');
document.write('                     	<option value="3">ALL nations including USA</option>');
document.write(' 						<option selected="selected" value="4">ALL nations excluding USA</option>');
document.write('                	</select>');
document.write('             </td>');
document.write('	 </tr>');
document.write(' </table>');
document.write('            <div>&nbsp;&nbsp;</div>');
document.write(getCompareButtonRow());
document.write('</form>');