document.write('<form name="form1" onsubmit="validate();" action="/results/exchangevisitor/" method="post">');
document.write('<div align="center">');
document.write('<table width="100%" border="1" align="center" cellPadding="0" cellSpacing="0" bordercolor="#B9D5FF" class="quote">');
document.write('<tbody align="left">');
document.write('    <tr vAlign="top">');
document.write('          <td width="3%" class="quoteformbg">&nbsp;<span class="formblackbold">1.</span></td>');
document.write('          <td width="50%" class="quoteformbg"><span class="formblackbold">');
document.write('				J1 Visitor&#39;s age</span></td>');
document.write('          <td colSpan="8" class="quoteformbg">');
document.write('                 <input onkeypress="return numbersonly(event);" maxLength="2" size="2" name="Age">'); 
document.write('				  <input type="hidden" value="zstudent" name="affiliate"></td>');
document.write('    </tr>');
document.write('    <tr vAlign="top">');
document.write('          <td class="formblackbold">&nbsp;2.</td>');
document.write('          <td class="formblackbold">J1 Visitor&#39;s spouse age 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 &amp; ages 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 width="9%" height="36" class="quoteformbg"> <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;<span class="formblackbold">4.</span> </td>');
document.write('            <td width="49%"><span class="formblackbold">');
document.write('					Select the coverage limit for medical expenses</span> ');
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">');
document.write('						<select onchange="questiondisplay4(this[this.selectedIndex].value);" name="MaxPolicyLimit" size="1">');
			var maxpolLim = new Array("50000","200000-300000", "300001-500000","500001-1000000");
			var mpl = new Array("$50,000","$200,000 to $300,000","$300,001 to $500,000","$500,001 to $1,000,000");
document.write(getMaxPolLimitHTML(maxpolLim, mpl, "200000-300000"));
document.write('							</select></td>');                                           
document.write('   </tr>');
document.write('   <tr vAlign="top">');
document.write('			<td width="3%" class="quoteformbg">&nbsp;<span class="formblackbold">5.</span></td>');
document.write('			<td width="49%" class="quoteformbg">');
document.write('				<span class="formblackbold">Select the deductible amount</span>'); 
document.write('                <div class="formsmallfont" style="PADDING-TOP: 2px">');
document.write('					The initial amount that you are responsible for before the insurance pays for medical expense.');
document.write('			</div></td>');
document.write('            <td colSpan="8" class="quoteformbg">');
document.write('                  <select size="1" name="Deductible">');
						var vdeductible=new Array("0","50-100","101-250", "500", "1000", "2500");
						var vdbl = new Array("US$ 0","US$ 50 to 100","US$ 101 to 250","US$ 500","US$ 1000","US$ 2500 ");
document.write(getDeductibleHTML(vdeductible, vdbl, "50-100"));	
document.write('                  </select></td>');
document.write('   </tr>');
document.write('   <tr vAlign="top">');
document.write('            <td width="3%" class="formblackbold">&nbsp;6.</td>');
document.write('            <td width="50%" class="formblackbold">Select the dates for coverage </td>');
document.write('            <td> <div>Start Date:&nbsp;</div><div>End Date:&nbsp;&nbsp;</div></td>');
document.write('            <td colSpan="6"> <div class="formsmallfont" style="PADDING-TOP: 2px">');
document.write('                 <select onchange="setperiods();" size="1" name="DepartureMonth">');
document.write(getMonthHTML());
document.write('                 </select>');
document.write('                 <select onchange="setperiods();" size="1" name="DepartureDay">');
document.write(getDayHTML());
document.write('				 </select>');
document.write('                 <select onchange="setperiods();" size="1" name="DepartureYear">');
document.write(getYearHTML());
document.write('                 </select>');
document.write('	            </font></div><div class="formsmallfont" style="PADDING-TOP: 2px"> ');
document.write('                  <select onchange="setperiods();" size="1" name="ReturnMonth">');
document.write(getMonthHTML());
document.write('				  </select>');
document.write('                  <select onchange="setperiods();" size="1" name="ReturnDay">');
document.write(getDayHTML());
document.write('				</select>');
document.write('                 <select onchange="setperiods();" size="1" name="ReturnYear">');
document.write(getYearHTML());
document.write('                 </select>&nbsp;&nbsp; ');
document.write('				<input name="monthsOfCoverage" readonly="true" size="1" value="1" maxlength="2">months');
document.write('				<input name="daysOfCoverage" readonly="true" size="1" value="0" maxlength="2"> days</font></div>');
document.write('           </td>');
document.write('    </tr>');
document.write('	<tr vAlign="top">');
document.write('            <td width="3%" class="quoteformbg">&nbsp;<span class="formblackbold">7.</span></td>');
document.write('             <td width="50%" class="quoteformbg"><span class="formblackbold">');
document.write('				Where is the mailing address </span> ');
document.write('				<div class="formsmallfont" style="PADDING-TOP: 2px">');
document.write('						Address to mail the insurance ID card and certificate</FONT></div></td>');
document.write('            <td colSpan="8" class="quoteformbg"> <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>');											
document.write('             </div></td>');
document.write('	</tr>');
document.write('	 <tr vAlign="top">');
document.write('            <td width="3%" class="formblackbold">8.</td>');
document.write('            <td width="49%" class="formblackbold">');
document.write('				Where is the J1 Visitor&#39;s permanent home  ');
document.write('				<div class="formsmallfont" style="PADDING-TOP: 2px">');
document.write('						Applicant&#39;s fixed/permanent home to which he/she has the intention of returning to.</FONT>');
document.write('				   </div></td>');
document.write('            <td colSpan="8"> <div id="q10c">');
document.write('				<select name="Residence" size="1">');
document.write('					<option selected="selected" value="2">Outside-USA </option>');
document.write( getUSStatesForCombo());
document.write('				</select>');												
document.write('            </div></td>');
document.write('	</tr>');
document.write('	<tr vAlign="top">');
document.write('            <td width="3%" class="quoteformbg" id="q11a"><span class="formblackbold">9.</span></td>');
document.write('            <td width="49%" class="quoteformbg" id="q11b"><span class="formblackbold">');
document.write('				Are you engaged in international education or research or cultural exchange program? </span></td>');
document.write('            <td colSpan="8" class="quoteformbg">');
document.write('				<select name="Research" size="1" >');
document.write('							<option selected="selected" value="1">YES</option>');
document.write('							<option value="0">NO</option>');
document.write('                </select> </td>');
document.write('	 </tr>');
document.write('	</tbody>');
document.write(' </table>');
document.write(getCompareButtonRow());
document.write('</div>');
document.write('</form>');