document.write('<form method="post" name="visitorminiform" action="/results/visitor/" onSubmit="visivalidate();">');
document.write('<table  id="visiquote" border="0" cellpadding="0" cellspacing="0" width="100%"  height="280" >');
document.write('    <tbody>');
document.write('       <tr> ');
document.write('         	<td height="25">Traveler&#39;s Age</td>');
document.write('            <td colspan="3" height="25"> <input size="2" name="Age" onkeypress="return numbersonly(event);" maxlength="2" ></td>');
document.write('       </tr>');
document.write('      <tr> ');
document.write('            <td height="25">Spouse&#39;s Age</td>');
document.write('            <td colspan="3" height="25"> <input size="2" name="spouseAge" onkeypress="return numbersonly(event);" maxlength="2" ></td>');
document.write('       </tr>');
document.write('       <tr> ');
document.write('            <td height="25">Max coverage </td>');
document.write('            <td colspan="3" height="25"> <select name="MaxPolicyLimit" size="1">');
			var maxpolLim = new Array("0-25000","26000-60000", "76000-100000", "101000-499000", "500000", "1000000", "5000000", "8000000");
			var mpl = new Array("$25,000 or less","$50K","$100K","$101K to $499K","$500K","$1,000K","$5,000K","$8,000K");
document.write(getMaxPolLimitHTML(maxpolLim, mpl, "26000-60000"));
document.write('                                      </select></td>');
document.write('         </tr>');
document.write('         <tr> ');
document.write('             <td nowrap height="25">Coverage Period</td>');
document.write('             <td nowrap height="25"> <input name="monthsOfCoverage" style="width: 20px;" value="1" onkeypress="return numbersonly(event);" maxlength="2" type="text" > months </td>');
//document.write('         </tr>');
//document.write('         <tr> ');
//document.write('			<td height="25"> &nbsp;&nbsp;</td>');
document.write('			<td nowrap height="25"> ');
document.write('			 <input name="daysOfCoverage" style="width: 20px;" value="0" onkeypress="return numbersonly(event);" maxlength="2" type="text" > days </td>');
document.write('         </tr>');
document.write('         <tr> ');
document.write('			 <td height="25" >Citizenship</td>');
document.write('			<td nowrap height="25"> ');
document.write('			 <input checked="checked" name="CountryofCitizenship" value="2" onclick="document.visitorminiform.CountryforCoverage.value=1;" type="radio" > Non US</td>');
//document.write('        </tr>');
//document.write('         <tr> ');
//document.write('         <td height="25" > &nbsp;&nbsp;</td>');
document.write('			<td nowrap height="25">');
document.write('			<input name="CountryofCitizenship" value="1" onclick="document.visitorminiform.CountryforCoverage.value=4;" type="radio" > US</td>');
document.write('         </tr>');
//document.write('		 <tr>');
//document.write('			<td height="10" align="center" colspan="4">');
document.write('						<input type="hidden" name="Deductible" value="101-250">');
document.write('						<input type="hidden" name="NumberOfChildren" value="0">');
document.write('						<input type="hidden" name="CountryforCoverage" value="1">');
document.write('						<input type="hidden" name="MailingAddress" value="2">');
document.write('						<input type="hidden" name="Residence" value="2">');
document.write('						<input type="hidden" name="USarrival" value="0">');
document.write('						<input type="hidden" name="P">');
document.write('						<input type="hidden" name="S">');
document.write('						<input type="hidden" name="mths">');
document.write('						<input type="hidden" name="dys">');
document.write('						<input type="hidden" name="x">');
document.write('						<input type="hidden" name="us">');
document.write('						<input type="hidden" name="affiliate" value="ztravel">');
//document.write('			</td>');
//document.write('		</tr>');
document.write('         <tr> ');
document.write('         <td colspan=4 height="35"><div align="center"> ');
document.write('		 <input class="formbuttonminivisi" onmouseover="this.className=&#39;formbuttonsubmitminivisi&#39;" onclick="visivalidate();" onmouseout="this.className=&#39;formbuttonminivisi&#39;" value=" Get Quote! " name="quote"  type="button" >');
//document.write('		 </td>');
//document.write('         <td colspan="3" height="35"><div align="center">');
document.write('		 <input class="formbuttonminivisi" onmouseover="this.className=&#39;formbuttonsubmitminivisi&#39;" onmouseout="this.className=&#39;formbuttonminivisi&#39;" value="More Options" name="quote2" onclick="visigomain();" type="button" ></div>');
document.write('		 </td');
document.write('         </tr>');
document.write('   </tbody>');
document.write('</table>');
document.write('</form>');