document.write('<form name="form1" onsubmit="validate();" action="/results/flight/" method="post">');
document.write('<div align="center"> ');
document.write('<table width="100%" border="1" cellpadding="1" cellspacing="0" class="quote" bordercolor="#B9D5FF">');
document.write('<tbody align="left">');
document.write('    <tr vAlign="top"> ');
document.write('          <td width="3%" class="quoteformbg"><span class="formblackbold">&nbsp;1.</span></td>');
document.write('          <td width="49%" class="quoteformbg"><span class="formblackbold">');
document.write('				Enter the age of the primary traveler</span></td>');
document.write('          <td colspan="8" width="57%" class="quoteformbg">');
document.write('                 <input onkeypress="return numbersonly(event);" maxLength="2" size="2" name="Age">'); 
document.write('				  <input type="hidden" name="affiliate" value="zflight"></td>');
document.write('    </tr>');
document.write('    <tr vAlign="top"> ');
document.write('          <td class="formblackbold">&nbsp;2.</td>');
document.write('          <td class="formblackbold">Enter age of the traveler&#39;s spouse if coverage for spouse is required</td>');
document.write('          <td colspan="8"><input onkeypress="return numbersonly(event);" maxLength="2" size="2" name="spouseAge"></td>');
document.write('    </tr>');
document.write('    <tr vAlign="top"> ');
document.write('           <td height="28" vAlign="top" class="quoteformbg"><span class="formblackbold">&nbsp;3.</span></td>');
document.write('           <td class="quoteformbg"><span class="formblackbold">');
document.write('               Enter number of dependents under 18 requiring coverage </span>'); 
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 colspan="8" class="quoteformbg"> <div> ');
document.write('				<select size="1" name="NumberOfChildren">');
document.write(getNoChildrenHTML());
document.write('				</select>');
document.write('           </div></td>');
document.write('	</tr>');
document.write('   <tr vAlign="top"> ');
document.write('            <td width="3%"><span class="formblackbold">&nbsp;4.</span> </td>');
document.write('            <td width="49%"><span class="formblackbold">');
document.write('					Select the coverage type</span></td> ');
document.write('            <td colspan="8"><span class="formblackbold">');
document.write('             		<input name="CoverageType" value="0" type="radio"> Flight Accident Death Benefits Only <br>');
document.write('               		<input name="CoverageType" value="1" type="radio"> Flight Accident Death & Medical Expense Benefits </span></td>');
document.write('   </tr>');
document.write('    <tr vAlign="top" > ');
document.write('           <td width="3%" class="quoteformbg"><span class="formblackbold">&nbsp;5. </span></td>');
document.write('           <td width="49%" class="quoteformbg"><span class="formblackbold">');
document.write('				Select the visitor/traveler&#39;s country of citizenship </span></td>');
document.write('           <td colspan="8" class="quoteformbg">');
document.write('				<select size="1" name="CountryofCitizenship">');
document.write('                     <option selected="selected" value="1">USA</option>');
document.write('                    <option value="2">Non USA</option>');
document.write('            </select> </td>');
document.write('    </tr>');
document.write('   <tr vAlign="top"> ');
document.write('			<td width="3%"><span class="formblackbold">&nbsp;6. </span></td>');
document.write('			<td width="49%">');
document.write('				<span class="formblackbold">Select the destination for coverage</span></td>'); 
document.write('            <td colspan="8">');
document.write('                  <select id="CountryforCoverage" name="CountryforCoverage">');
document.write('                     <option selected="selected" value="1">Including USA</option>');
document.write('                    <option value="2">Excluding USA</option>');
document.write('                  </select></td>');
document.write('   </tr>');
document.write('	 <tr vAlign="top"> ');
document.write('            <td width="3%" class="quoteformbg"><span class="formblackbold">&nbsp;7. </span></td>');
document.write('            <td width="49%" class="quoteformbg"><span class="formblackbold">');
document.write('				What is the Coverage Period? </span></td>');
document.write('            <td colspan="4" class="quoteformbg"><select size="1" name="CoveragePeriod" onchange="showhideTripLength(this[this.selectedIndex].value);">');
document.write('                    <option selected="selected" value="2">Select Trip Type</option>');
document.write('                    <option value="Annual">Multi Trips for a year</option>');
document.write('                    <option value="Single">Single Trip</option>');                                            
document.write('            </select></td>');
document.write('            <td colspan="3" id="TripLength1"  class="quoteformbg"></td>');
document.write('	</tr>');
document.write('	 <tr vAlign="top"> ');
document.write('            <td width="3%"><span class="formblackbold">&nbsp;8. </span></td>');
document.write('            <td width="49%"><span class="formblackbold">');
document.write('				Where is the traveler/visitor&#39;s permanent home? </span>');
document.write('                   <div style="padding-top: 2px" class="formsmallfont">');
document.write('						Applicant&#39;s fixed/permanent home to which he/she has the intention of returning to.');
document.write('				   </div></td>');
document.write('            <td colspan="8">');
document.write('				<select name="Residence" size="1">');
document.write('					<option value="2">Outside-USA </option>');
document.write('<option selected="selected" value="AL">AL Alabama</option><option value="AK">AK Alaska</option><option value="AZ">AZ Arizona</option><option value="AR">AR Arkansas</option><option value="CA">CA California</option><option value="CO">CO Colorado</option><option value="CT">CT Connecticut</option><option value="DE">DE Delaware</option><option value="DC">DC District of Columbia</option><option value="FL">FL Florida</option><option value="GA">GA Georgia</option><option value="HI">HI Hawaii</option><option value="ID">ID Idaho</option><option value="IL">IL Illinois</option><option value="IN">IN Indiana</option><option value="IA">IA Iowa</option><option value="KS">KS Kansas</option><option value="KY">KY Kentucky</option><option value="LA">LA Louisiana</option><option value="ME">ME Maine</option><option value="MD">MD Maryland</option><option value="MA">MA Massachusetts</option><option value="MI">MI Michigan</option><option value="MN">MN Minnesota</option><option value="MS">MS Mississippi</option><option value="MO">MO Missouri</option><option value="MT">MT Montana</option><option value="NE">NE Nebraska</option><option value="NV">NV Nevada</option><option value="NH">NH New Hampshire</option><option value="NJ">NJ New Jersey</option><option value="NM">NM New Mexico</option><option value="NY">NY New York</option><option value="NC">NC North Carolina</option><option value="ND">ND North Dakota</option><option value="OH">OH Ohio</option><option value="OK">OK Oklahoma</option><option value="OR">OR Oregon</option><option value="PA">PA Pennsylvania</option><option value="RI">RI Rhode Island</option><option value="SC">SC South Carolina</option><option value="SD">SD South Dakota</option><option value="TN">TN Tennessee</option><option value="TX">TX Texas</option><option value="UT">UT Utah</option><option value="VT">VT Vermont</option><option value="VA">VA Virginia</option><option value="WA">WA Washington</option><option value="WV">WV West Virginia</option><option value="WI">WI Wisconsin</option><option value="WY">WY Wyoming</option>');
document.write('				</select>');												
document.write('            </div></td>');
document.write('	</tr>');
document.write('	<tr vAlign="top" > ');
document.write('            <td width="3%" class="quoteformbg"><span class="formblackbold">&nbsp;9. </span></td>');
document.write('            <td width="49%" class="quoteformbg"><span class="formblackbold">');
document.write('				Do you have Primary Insurance? </span>');
document.write('                    <div style="padding-top: 2px" class="formsmallfont">');
document.write('						ie Employee Group Health Insurance, Individual/Family Health Insurance Private or Govt. (Medicare).</div></td>');
document.write('            <td  colspan="8" class="quoteformbg"><span class="formblackbold">');
document.write('                		<input name="PrimaryInsurance" checked="checked" value="1" type="radio"> Yes &nbsp; &nbsp;');
document.write('                		<input name="PrimaryInsurance" value="0" type="radio"> No </span>');
document.write('			</td>');
document.write('	 </tr>');
document.write('	</tbody>');
document.write(' </table>');
document.write(getCompareButtonRow());
document.write('</div>');
document.write('</form>');