document.write('<form method="post" name="globalminiform" action="/results/global/" onSubmit="glbvalidate();">');
document.write('<table id="globalquote" border="0" cellpadding="0" cellspacing="0" width="100%"  height="280" title="For Global Coverage including your country of citizenship you can consider the Long Term International Health Insurance plans" >');
document.write('<tbody>');
document.write('<tr>');
document.write('	<td width="100" height="25"  >Applicant</td> ');
document.write('	<td nowrap >Age ');
document.write('		<input size="2" name="Age" onkeypress="return numbersonly(event);" maxlength="2">&nbsp;Gender');
document.write('		<select name="pgender" size="1" onChange="FixGender(this[this.selectedIndex].value,&#39;p&#39;);">');
document.write('			<option value="M" selected="selected">Male</option>');
document.write('			<option value="F">Female</option>');
document.write('		</select></td>');
document.write('</tr>');
document.write('<tr>'); 
document.write('	<td width="100" height="25" >Spouse</td>');
document.write('	<td nowrap  >Age');
document.write('	<input size="2" name="spouseAge" onkeypress="return numbersonly(event);" maxlength="2"">&nbsp;Gender ');
document.write('		<select name="sgender" size="1" onChange="FixGender(this[this.selectedIndex].value,&#39;p&#39;);">');
document.write('			<option value="M">Male</option>');
document.write('			<option value="F" selected="selected">Female</option>');
document.write('              </select></td>');
document.write('	</tr>');
document.write('	<tr> ');
document.write('	<td width="100" height="25" >Deductible</td>');                              
document.write('                  <td height="25" ><select size="1" name="Deductible">');
var vdeductible=new Array("0","50-100", "101-250", "500", "1000", "2500", "5000","10000", "25000");
var vdbl = new Array("US$ 0","US$ 50 to 100","US$ 101 to 250","US$ 500","US$ 1000 ","US$ 2500 ","US$ 5000 ","US$ 10000 ","US$ 25000 ");
document.write(getDeductibleHTML(vdeductible, vdbl, "500"));
document.write('             </select> </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 &nbsp;&nbsp;');
document.write('			<input name="CountryofCitizenship" value="1" onclick="document.visitorminiform.CountryforCoverage.value=4;" type="radio" > US</td>');
document.write('         </tr>');
document.write('  <tr valign="middle"> ');
document.write('  <td height="25" colspan="1">Coverage</td>');
document.write('  <td height="25" colspan="3">');
document.write('  <select name="CountryforCoverage" style="width: 125px;">');
document.write('                <option value="1" selected="selected">All Incl USA (Excl Canada)</option>');
document.write('                <option value="4">All Excl USA & Canada</option>');
document.write('              </select> </td>');
document.write('  </tr>');
document.write('          <tr> ');
document.write('            <td height="1" colspan="4" align="right" valign="top">');
document.write('		<input type="hidden" name="paymentType" value="1">');
document.write('		<input type="hidden" name="NumberOfChildren" value="0">');
document.write('		<input type="hidden" name="affiliate" value="iexpat">');
document.write('		<input type="hidden" name="MailingAddress" value="2">');
document.write('		<input type="hidden" name="Residence" value="2">');
document.write('		<input type="hidden" name="P"><input type="hidden" name="PG">');
document.write('		<input type="hidden" name="S"><input type="hidden" name="SG">');
document.write('		<input type="hidden" name="cv"><input type="hidden" name="d"><input type="hidden" name="us">');
document.write('	    </td>');
document.write('          </tr>');
document.write('  <tr> ');
document.write('  <td height="35"  colspan="5">');
document.write('  <div align="center"><br>&nbsp;<br><input class="formbuttonminiglobal" onmouseover="this.className=&#39;formbuttonminiglobalsubmit&#39;" onmouseout="this.className=&#39;formbuttonminiglobal&#39;" value=" Get Quote! " name="quote"  type="button" onclick="glbvalidate();"> ');
document.write('  <input class="formbuttonminiglobal" onmouseover="this.className=&#39;formbuttonminiglobalsubmit&#39;" onmouseout="this.className=&#39;formbuttonminiglobal&#39;" value="More Options" name="quote2" onclick="glbgomain();" type="button"></div> </td>');
document.write('  </tr>');
document.write('  </tbody>');
document.write('</table>');
document.write('</form>');