document.write('<form name="form1" onsubmit="validate();" method="post" action="/results/students/">');
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'>Student&#39;s age</td>");
document.write("    <td width=47%' colspan='8' class='formbg'><input size='2' name='Age' onKeyPress='return numbersonly(event);' maxlength='2' >");
document.write("		<input name='affiliate' type='hidden' value='zstudent'></td>");
document.write(" </tr>");
document.write("<tr valign='top'>");
document.write("    <td>&nbsp;2.</td>");
document.write("    <td>Student&#39;s spouse age if coverage for spouse is required</td>");
document.write("    <td colspan='8'><input size='2' name='spouseAge' onKeyPress='return numbersonly(event);' maxlength='2'></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 coverage limit for medical expenses.");
document.write("         <div class='formsmallfont'>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 $1,000,000");
document.write(getMaxPolLimitHTML(maxpolLim, mpl, "200000-300000")); 	
document.write("                  </select></td>");
document.write("</tr>");
document.write(" <tr valign='top'>");
document.write("     <td class='formbg'>&nbsp;5.</td>");
document.write("     <td class='formbg'>Select the deductible amount");
document.write("         <div class='formsmallfont'>The initial amount that you are responsible for before the insurance pays for medical expense.</div></td>");
document.write("      <td colspan='8' class='formbg'><select name='Deductible' size='1'>");
						var vdeductible=new Array("0","50-100","101-250", "500", "1000", "2500");
						var vdbl = new Array("US$ 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>&nbsp;6. </td>");
document.write("    <td >Select the dates for coverage </td>");
document.write("    <td ><div>Start Date:&#160;</div><div >End Date:&#160;&#160;</div></td>");
document.write("    <td colspan='6'><div class='formSmallFont'><select name='DepartureMonth' size='1' onChange='setperiods();'>");
document.write(getMonthHTML());
document.write("                </select>");
document.write("                <select name='DepartureDay' size='1' onChange='setperiods();'>");
document.write(getDayHTML());
document.write("                </select>");
document.write("                <select name='DepartureYear' size='1' onChange='setperiods();'>");
document.write(getYearHTML());
document.write("                </select></div>");
document.write("                 <div><select name='ReturnMonth' size='1' onChange='setperiods();'>");
document.write(getMonthHTML());
document.write("                  </select>");
document.write("                  <select name='ReturnDay' size='1' onChange='setperiods();'>");
document.write(getDayHTML());
document.write("                  </select>");
document.write("                  <select name='ReturnYear' size='1' onChange='setperiods();'>");
document.write(getYearHTML());
document.write("                  </select>");
document.write("&#160;&#160;");
document.write("<input name='monthsOfCoverage' readonly='true' size='1' value='1' maxlength='2' />months &#160;");
document.write("<input name='daysOfCoverage' readonly='true' size='1' value='0' maxlength='2' /> days</div>");
document.write("                </td>");
document.write("</tr>");
document.write(" <tr valign='top'>");
document.write("     <td class='formbg'>&nbsp;7.</td>");
document.write("     <td class='formbg'>Select the student&#39;s country of  citizenship</td>");
document.write("      <td colspan='8' class='formbg'><select onchange='questiondisplay7(this[this.selectedIndex].value);' size='1' name='CountryofCitizenship'>");
document.write(getCtyCitizenshipHTML());
document.write('            </select> </td>');
document.write("</tr>");
document.write(" <tr valign='top'>");
document.write("    <td>&nbsp;8. </td>");
document.write("    <td>Select the country/countries where coverage is required</td>");
document.write("     <td colspan='8'><div id='q8'>");
document.write('                  <select size="1" name="CountryforCoverage">');
document.write('						<option selected value="1">USA only</option>');
document.write('						<option value="4">ALL nations excluding USA</option>');
document.write('				 </select>');
document.write("    </div></td>");
document.write("</tr>");
document.write("<tr valign='top'>");
document.write("    <td  class='formbg'>&nbsp;9. </td>");
document.write("     <td class='formbg'>Where is the mailing address");
document.write("            <div class='formsmallfont'>Address to mail the insurance ID card and certificate</div></td>");
document.write("      <td class='formbg' 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 valign='top'>");
document.write("    <td>10.</td> ");
document.write("    <td>Where is the student&#39;s permanent home");
document.write("        <div class='formsmallfont'>Applicant&#39;s fixed/permanent home to which he/she has the intention of returning to.</div></td>");
document.write("    <td colspan='8'><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></td>");	
document.write(" </tr>");
document.write("<tr valign='top'>");
document.write("    <td  class='formbg' id='q11a'>11. </td>");
document.write("    <td class='formbg' id='q11b'>Are you engaged full time in international education or research activities?</td>");
document.write("    <td class='formbg' colspan='8'><div id='q9c'>");
document.write("              <select name='Research' size='1' onChange='questiondisplay(this[this.selectedIndex].value);'>");
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></table>");
document.write("<br />");
document.write(getCompareButtonRow());
document.write("</form>");