document.write('		<form method="post" name="form1" action="/concise.asp">');
document.write('<table width="310px" border="0" cellpadding="0" cellspacing="0" align="center">');
document.write('<tr>');
document.write('<td valign="top" style="width:310x;">');
document.write('	<img src="/images/europe-travel-medical-insurance-box1.gif" height="40" alt="Europe Travel Insurance">');
document.write('</td>');
document.write('</tr>');
document.write('<tr>');
document.write('	<td class="minicomparebg" valign="top" alt="Europe Travel Insurance">');
document.write('		<div align="center">');
document.write('		<table align="center" cellpadding="2" width="98%" cellspacing="0" border="0">');
document.write('			<tr valign="middle"> ');
document.write('				<td style="width:130px;height:25px;"><span class="whiteboldfont">Visitor&#39;s Age</span></td>');
document.write('				<td style="height:25px;" colspan="4"> <input size="2" name="Age" onkeypress="return numbersonly(event);" maxlength="2"></td>');
document.write('			</tr>');
document.write('		          <tr valign="middle"> ');
document.write('		            <td><span class="whiteboldfont">Spouse age</span></td>');
document.write('		            <td colspan="4"> <input size="2" name="spouseAge" onkeypress="return numbersonly(event);" maxlength="2">	');
document.write('		            </td>');
document.write('		    </tr>');
document.write('		    <tr valign="middle"> ');
document.write('		            <td><span class="whiteboldfont">Max coverage </span></td>');
document.write('		            <td height="25" colspan="4"> <select name="MaxPolicyLimit" size="1">');
document.write('		            	<option selected value="50000">$50,000</option>');
document.write('		            	<option value="100000">$100,000</option>');
document.write('		            	<option value="250000">$250,000</option>');
document.write('		            	<option value="500000">$500,000</option>');
document.write('		            	<option value="1000000">$1,000,000</option>');
document.write('		              </select></td>');
document.write('		    </tr>');
document.write('		    <tr valign="middle"> ');
document.write('		            <td><span class="whiteboldfont">Coverage Period</span></td>');
document.write('		            <td style="width:25px;" align="left"> ');
document.write('		              <input name="monthsOfCoverage" style="width:25px;" value="0" onkeypress="return numbersonly(event);" maxlength="2" type="text"> ');
document.write('		            </td>');
document.write('		            <td style="width:60px;" align="left" class="whiteboldfont">months</td>');
document.write('		            <td style="width:10px;" align="left" class="whiteboldfont"> ');
document.write('		              <input name="daysOfCoverage" style="width:25px;" value="14" onkeypress="return numbersonly(event);" maxlength="2" type="text"> ');
document.write('		            </td>');
document.write('		            <td  style="width:60px;" align="left" class="whiteboldfont">days</td>');
document.write('		    </tr>');
document.write('		    <tr valign="middle"> ');
document.write('		            <td><span class="whiteboldfont">Your mailing state</span></td>');
document.write('		            <td align="left" colspan="2"><input type="radio" name="location" value="NY"><span class="whiteboldfont">New York</span></td>');
document.write('		            <td align="left" colspan="2">');
document.write('		              <input type="radio" name="location" value="others" checked="checked"><span class="whiteboldfont">Others</span>');
document.write('		            </td>');
document.write('		    </tr>');
document.write('		          <tr> ');
document.write('		            <td height="1" colspan="5" align="right" valign="top" >');
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="4">');
document.write('						<input type="hidden" name="MailingAddress" value="2">');
document.write('						<input type="hidden" name="Residence" value="2">');
document.write('						<input type="hidden" name="CountryofCitizenship" value="2">');
document.write('            <input type="hidden" name="P"/><input type="hidden" name="S"/><input type="hidden" name="mths"/>');
document.write('            <input type="hidden" name="dys"/><input type="hidden" name="x"/><input type="hidden" name="gc" />');
document.write('			<input type="hidden" name="mail_state" />');
document.write('					</td>');
document.write('		          </tr>');
document.write('		  </table>');
document.write('		  <table width="90%" border="0" cellpadding="0" cellspacing="0">');
document.write('			<tr>');
document.write('		          <td align="center">');
document.write('					<input type="button" name="quote" value=" Get Quote! " onMouseOver="this.className=&#39;submitbuttonon&#39;" onMouseOut="this.className=&#39;submitbutton&#39;" class="submitbutton" onClick="validate();">');
document.write('		          </td>');
document.write('		          <td align="center">');
document.write('		          <input type="button" value="More Options" name="quote2" onMouseOver="this.className=&#39;submitbuttonon&#39;" onMouseOut="this.className=&#39;submitbutton&#39;" class="submitbutton" onClick="goMain();">');
document.write('		          </td>');
document.write('		    </tr>');
document.write('		  </table>');
document.write('	  </div>');
document.write('    </td>');
document.write(' </tr>');
document.write('</table>');
document.write('	  </form>	');