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var k='<option value="">MM</option><option value="1">01</option><option value="2">02</option><option value="3">03</option><option value="4">04</option><option value="5">05</option><option value="6">06</option><option value="7">07</option><option value="8">08</option><option value="9">09</option><option value="10">10</option><option value="11">11</option><option value="12">12</option>';
var l='<option value="">DD</option><option value="1">01</option><option value="2">02</option><option value="3">03</option><option value="4">04</option><option value="5">05</option><option value="6">06</option><option value="7">07</option><option value="8">08</option><option value="9">09</option><option value="10">10</option><option value="11">11</option><option value="12">12</option><option value="13">13</option><option value="14">14</option><option value="15">15</option><option value="16">16</option><option value="17">17</option><option value="18">18</option><option value="19">19</option><option value="20">20</option><option value="21">21</option><option value="22">22</option><option value="23">23</option><option value="24">24</option><option value="25">25</option><option value="26">26</option><option value="27">27</option><option value="28">28</option><option value="29">29</option><option value="30">30</option><option value="31">31</option>';
var f='<option value="" selected>YYYY</option><option value="2007">2007</option><option value="2006">2006</option><option value="2005">2005</option><option value="2004">2004</option><option value="2003">2003</option><option value="2002">2002</option><option value="2001">2001</option><option value="2000">2000</option><option value="1999">1999</option><option value="1998">1998</option><option value="1997">1997</option><option value="1996">1996</option><option value="1995">1995</option><option value="1994">1994</option><option value="1993">1993</option><option value="1992">1992</option><option value="1991">1991</option><option value="1990">1990</option><option value="1989">1989</option><option value="1988">1988</option><option value="1987">1987</option><option value="1986">1986</option><option value="1985">1985</option><option value="1984">1984</option><option value="1983">1983</option><option value="1982">1982</option><option value="1981">1981</option><option value="1980">1980</option><option value="1979">1979</option><option value="1978">1978</option><option value="1977">1977</option><option value="1976">1976</option><option value="1975">1975</option><option value="1974">1974</option><option value="1973">1973</option><option value="1972">1972</option><option value="1971">1971</option><option value="1970">1970</option><option value="1969">1969</option><option value="1968">1968</option><option value="1967">1967</option><option value="1966">1966</option><option value="1965">1965</option><option value="1964">1964</option><option value="1963">1963</option><option value="1962">1962</option><option value="1961">1961</option><option value="1960">1960</option><option value="1959">1959</option><option value="1958">1958</option><option value="1957">1957</option><option value="1956">1956</option><option value="1955">1955</option><option value="1954">1954</option><option value="1953">1953</option><option value="1952">1952</option><option value="1951">1951</option><option value="1950">1950</option><option value="1949">1949</option><option value="1948">1948</option><option value="1947">1947</option><option value="1946">1946</option><option value="1945">1945</option><option value="1944">1944</option><option value="1943">1943</option><option value="1942">1942</option><option value="1941">1941</option><option value="1940">1940</option><option value="1939">1939</option><option value="1938">1938</option><option value="1937">1937</option><option value="1936">1936</option><option value="1935">1935</option><option value="1934">1934</option><option value="1933">1933</option><option value="1932">1932</option><option value="1931">1931</option><option value="1930">1930</option><option value="1929">1929</option><option value="1928">1928</option><option value="1927">1927</option><option value="1926">1926</option><option value="1925">1925</option><option value="1924">1924</option><option value="1923">1923</option><option value="1922">1922</option><option value="1921">1921</option><option value="1920">1920</option><option value="1919">1919</option><option value="1918">1918</option><option value="1917">1917</option><option value="1916">1916</option><option value="1915">1915</option><option value="1914">1914</option><option value="1913">1913</option><option value="1912">1912</option><option value="1911">1911</option><option value="1910">1910</option><option value="1909">1909</option><option value="1908">1908</option><option value="1907">1907</option>';
var d='<option value="" selected>Ft</option><option value=0>0</option><option value=1>1</option><option value=2>2</option><option value=3>3</option><option value=4>4</option><option value=5>5</option><option value=6>6</option><option value=7>7</option>';
var e='<option value="" selected>In</option><option value=0>0</option><option value=1>1</option><option value=2>2</option><option value=3>3</option><option value=4>4</option><option value=5>5</option><option value=6>6</option><option value=7>7</option><option value=8>8</option><option value=9>9</option><option value=10>10</option><option value=11>11</option>';
var c='<option value="" selected>LBS</option><option value="80">80</option><option value="81">81</option><option value="82">82</option><option value="83">83</option><option value="84">84</option><option value="85">85</option><option value="86">86</option><option value="87">87</option><option value="88">88</option><option value="89">89</option><option value="90">90</option><option value="91">91</option><option value="92">92</option><option value="93">93</option><option value="94">94</option><option value="95">95</option><option value="96">96</option><option value="97">97</option><option value="98">98</option><option value="99">99</option><option value="100">100</option><option value="101">101</option><option value="102">102</option><option value="103">103</option><option value="104">104</option><option value="105">105</option><option value="106">106</option><option value="107">107</option><option value="108">108</option><option value="109">109</option><option 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var g=(new Date()).getFullYear();
var v="https://seal.verisign.com/splash?form_file=fdf/splash.fdf&dn=WWW.INSURELANE.COM&lang=en";
var r="<img src='http://www.insurelane.com/images/secure-lock.jpg' style=\"padding-left:65px\"/>";
var n="http://www.insurelane.com/partners/il_step_1/";
document.write('<link rel="stylesheet" href="'+n+'js-multistep-health.css" />'+'<script src="'+n+'multistep.healthfrm.validation-test.js"></scr'+'ipt>'+'<div style="text-align: center;">'+'<div align="center" id="progress-bar"><ul><li id="position1" class="active">Start</li><li id="position2" class="inactive">Your Health</li><li id="position3" class="inactive">Your Family</li><li id="position4" class="inactive" style="margin-right:0px;">Get Quotes</li></ul></div>'+'<div class="il_border">'+'<div align="left" style="padding-left: 10px;">'+'<form name="HealthForm" action="https://www.brokeroffice.com/leads/leadSave.do" method="post">'+'<input type="hidden" name="config_id" id="config_id" value="'+((o['config_id']!=undefined)?o['config_id']:"1")+'">'+'<input type="hidden" name="link_id" id="link_id" value="">'+'<input type="hidden" name="affiliate_id" id="affiliate_id" value="6">'+'<input type="hidden" name="custom_lead_url" id="custom_lead_url" value="'+((document.location.href)?document.location.href:"")+'">'+'<input type="hidden" name="custom_ref_url" id="custom_ref_url" value="'+((document.referrer)?document.referrer:"")+'">'+'<input type="hidden" name="custom_subaff" id="custom_subaff" value="'+((o['custom_subaff']!=undefined)?o['custom_subaff']:"")+'">'+'<input type="hidden" name="redirect" id="redirect" value="quotes">'+'<input type="hidden" name="type" value="Complete">');
document.write('<div id="step1">'+'<h3>Get Free Quotes from Local Agents</h3>'+'<div align="left" class="msg">Expert agents are ready to help you find your health plan. Start here for free competitive quotes...</div>'+'<table align="center" width="350" cellpadding="0" cellspacing="6" border="0" class="il_border">'+'<tr>'+'<td width="103"><strong id="lbl_applicant1">Gender:</strong></td>'+'<td width="247" colspan="3">Male&nbsp;<input type="radio" class="radio" name="insured_1_gender" id="insured_1_gender" value="Male" />&nbsp;&nbsp;&nbsp;Female&nbsp;<input type="radio" class="radio" name="insured_1_gender" id="insured_1_gender2" value="Female" /></td>'+'</tr>'+'<tr>'+'<td nowrap="nowrap"><strong id="lbl_applicant2">Date of birth:</strong></td>'+'<td colspan="3">'+'<select name="insured_1_dobMM" id="insured_1_dobMM" size="1" style="width:45px;">'+k+'</select>'+'<select name="insured_1_dobDD" id="insured_1_dobDD" size="1" style="width:45px;">'+l+'</select>'+'<select name="insured_1_dobYYYY" id="insured_1_dobYYYY" size="1" style="width:59px;">'+f+'</select>'+'</td>'+'</tr>'+'<td><strong id="lbl_applicant3">Height:</strong></td>'+'<td nowrap="nowrap" width="100">'+'<select name="insured_1_heightFT" id="insured_1_heightFT" style="width:45px;">'+d.replace("<option value=0>0</option><option value=1>1</option><option value=2>2</option><option value=3>3</option>","")+'</select>'+'<select name="insured_1_heightIN" id="insured_1_heightIN" style="width:45px;">'+e+'</select>'+'</td>'+'<td align="right" width="80"><strong id="lbl_applicant4">Weight:</strong></td>'+'<td align="left" width="200"><select name="insured_1_weight">'+c+'</select></td>'+'</tr>'+'</table>'+'<div id="form-button"><div align="left" style="float:left;width:200px;">'+r+'</div><div style="padding-top:25px;"><input type="button" value="Continue" id="button2" onclick="return chkHealthForm1(this.form);" /></div></div>'+'</div>');
document.write('<div id="step2" style="display:none;">'+'<h3>Your Health History</h3>'+'<div class="msg">To match you with the right plan, please give us a snapshot of your medical history.</div>'+'<table align="center" width="350" cellpadding="0" cellspacing="6" border="0">'+'<tr>'+'<td width="130" align="right"><strong id="lbl_applicant5">Currently insured?</strong></td>'+'<td align="left">'+'Yes&nbsp;<input type="radio" class="radio" name="insured_1_currently_covered" value="yes" />&nbsp;&nbsp;&nbsp;'+'No&nbsp;<input type="radio" class="radio" name="insured_1_currently_covered" value="no" checked="checked" />'+'</td>'+'</tr>'+'<tr>'+'<td align="right"><strong id="lbl_applicant6">Smoker?</strong></td>'+'<td align="left">'+'Yes&nbsp;<input type="radio" class="radio" name="insured_1_smoker" id="insured_1_smoker" value="Yes">&nbsp;&nbsp;&nbsp;'+'No&nbsp;<input type="radio" class="radio" name="insured_1_smoker" id="insured_1_smoker2" value="NO" checked="checked">'+'</td>'+'</tr>'+'<tr>'+'<td nowrap="nowrap" align="right"><strong id="lbl_applicant7">Medical conditions?</strong></td>'+'<td align="left">'+'Yes&nbsp;<input type="radio" class="radio" name="insured_1_health_conditions" id="insured_1_health_conditions_yes" value="yes" onclick="if(this.checked){document.getElementById(\'comment1\').style.display=display;}">&nbsp;&nbsp;&nbsp;'+'No&nbsp;<input type="radio" class="radio" name="insured_1_health_conditions" id="insured_1_health_conditions_no" value="no" checked onclick="if(this.checked){document.getElementById(\'comment1\').style.display=\'none\';}unSetConditions();">'+'<input name="insured_1_health_conditions_detail" id="insured_1_health_conditions_detail" type="hidden">'+'</td>'+'</tr>'+'</table>'+'<table id="comment1" align="center" cellpadding="4" cellspacing="2" border="0" style="margin-bottom:4px;display:none;">'+'<tr valign="top" align="left">'+'<td width="100"><input id="aids" type="checkbox" class="radio" onclick="setConditions();" />HIV/AIDS</td>'+'<td><input id="diabetes" type="checkbox" class="radio" onclick="setConditions();" />Diabetes</td>'+'<td><input id="cancer" type="checkbox" class="radio" onclick="setConditions();" />Cancer</td>'+'</tr>'+'<tr valign="top" align="left">'+'<td><input id="heart-attack" type="checkbox" class="radio" onclick="setConditions();" />Heart attack</td>'+'<td><input id="high-blood-pressure" type="checkbox" class="radio" onclick="setConditions();" />High blood pressure</td>'+'<td><input id="asthma" type="checkbox" class="radio" onclick="setConditions();" />Asthma</td>'+'</tr>'+'<tr valign="top" align="left">'+'<td><input id="stroke" type="checkbox" class="radio" onclick="setConditions();" />Stroke</td>'+'<td nowrap="nowrap"><input id="depression" type="checkbox" class="radio" onclick="setConditions();" />Depression requiring medication&nbsp;&nbsp;&nbsp;</td>'+'<td><input id="other-illness" type="checkbox" class="radio" onclick="setConditions();" />Other major illness</td>'+'</tr>'+'</table>'+'<div id="form-button">'+'<div align="left" style="float: left; width: 200px;">'+r+'</div>'+'<div style="padding-top: 25px;"><input type="button" value="Continue" id="button2" onclick="return chkHealthForm2(this.form);" /></div></div>'+'<div class="backbutton"><a href="#" onclick="formStepBack();">&lt;&lt; Need to go back?</a></div></div>');document.write('<div id="step3" style="display:none;">'+'<h3>Your Family</h3>'+'<table align="center" width="403" cellpadding="0" cellspacing="6" border="0">'+'<tr>'+'<td nowrap="nowrap" colspan="4">'+'<strong id="lbl_spouse1">Do you have a spouse who needs insurance?</strong>&nbsp;&nbsp;&nbsp;'+'Yes&nbsp;<input type="radio" class="radio" name="spouse_needs_insurance" id="spouse_needs_insurance" value="Yes"onclick="if(this.checked){document.getElementById(\'spouse1\').style.display=display;document.getElementById(\'spouse2\').style.display=display;document.getElementById(\'spouse3\').style.display=display;document.getElementById(\'spouse4\').style.display=display;}">&nbsp;&nbsp;'+'No&nbsp;<input type="radio" class="radio" name="spouse_needs_insurance" id="spouse_needs_not_insurance" value="No" checked onclick="if(this.checked){document.getElementById(\'spouse1\').style.display=\'none\';document.getElementById(\'spouse2\').style.display=\'none\';document.getElementById(\'spouse3\').style.display=\'none\';document.getElementById(\'spouse4\').style.display=\'none\';}resetSpouseInfo(this.form);">'+'</td>'+'</tr>'+'<tr id="spouse1" style="display:none;">'+'<td width="103"><strong id="lbl_spouse2">Gender:</strong></td>'+'<td width="247" colspan="3">'+'Male&nbsp;<input type="radio" class="radio" name="insured_2_gender" id="insured_2_gender" value="Male" />&nbsp;&nbsp;'+'Female&nbsp;<input type="radio" class="radio" name="insured_2_gender" id="insured_2_gender2" value="Female" />'+'</td>'+'</tr>'+'<tr id="spouse2" style="display:none;">'+'<td nowrap="nowrap"><strong id="lbl_spouse3">Date of birth:</strong></td>'+'<td colspan="3">'+'<select name="insured_2_dobMM" id="insured_2_dobMM" size="1" style="width:45px;">'+k+'</select>'+'<select name="insured_2_dobDD" id="insured_2_dobDD" size="1" style="width:45px;">'+l+'</select>'+'<select name="insured_2_dobYYYY" id="insured_2_dobYYYY" size="1" style="width:59px;">'+f+'</select>'+'</td>'+'</tr>'+'<tr id="spouse3" style="display:none;">'+'<td><strong id="lbl_spouse4">Height:</strong></td>'+'<td nowrap="nowrap" width="100">'+'<select name="insured_2_heightFT" id="insured_2_heightFT" style="width:45px;">'+d+'</select>'+'<select name="insured_2_heightIN" id="insured_2_heightIN" style="width:45px;">'+e+'</select>'+'</td>'+'<td align="right" width="80"><strong id="lbl_spouse5">Weight:</strong></td>'+'<td align="left" width="200">'+'<select name="insured_2_weight" id="insured_2_weight">'+c+'</select>'+'</td>'+'</tr>'+'<tr id="spouse4" style="display:none;">'+'<td><strong id="lbl_spouse6">Smoker?</strong></td>'+'<td colspan="3">'+'<input name="insured_2_smoker" id="insured_2_smoker" value="YES" type="checkbox">'+'</td>'+'</tr>'+'<tr>'+'<td width="103"><strong>Children</strong></td>'+'<td align="left" width="300" colspan="3">'+

'<select name="number_of_dependents" id="number_of_dependents" size="1" onChange="changeChildren(this.value,this.form)">'+
'<option value="0">0&nbsp;</option>'+
'<option value="1">1</option>'+
'<option value="2">2</option>'+
'<option value="3">3</option>'+
'<option value="4">4</option>'+
'<option value="5">5</option>'+
'<option value="6">6</option>'+
'</select>'+
'</td>'+
'</tr>'+
'</table>'+
'<table id="child_option" style="display:none;" align="center" width="406" cellpadding="4" cellspacing="6" border="0">'+
'<tr><td colspan="5" align="left"><strong id="lbl_child1">Child 1</strong></td></tr>'+
'<tr>'+
'<td width="15"></td>'+
'<td width="103"><strong id="lbl_child1_1">Gender:</strong></td>'+
'<td width="247" colspan="3">'+
'Male&nbsp;<input type="radio" class="radio" name="insured_3_gender" id="insured_3_gender" value="Male" />&nbsp;&nbsp;'+
'Female&nbsp;<input type="radio" class="radio" name="insured_3_gender" id="insured_3_gender2" value="Female" />'+'</td>'+'</tr>'+'<tr>'+'<td></td>'+'<td nowrap="nowrap"><strong id="lbl_child1_2">Date of birth:</strong></td>'+'<td colspan="3">'+'<select name="insured_3_dobMM" id="insured_3_dobMM" size="1" style="width:45px;">'+k+'</select>'+'<select name="insured_3_dobDD" id="insured_3_dobDD" size="1" style="width:45px;">'+l+'</select>'+'<select name="insured_3_dobYYYY" id="insured_3_dobYYYY" size="1" style="width:59px;" onChange="if(('+g+'-(this.value))>=18){document.getElementById(\'insured_3_smoker_tr\').style.display=display;}else{document.getElementById(\'insured_3_smoker_tr\').style.display=\'none\';}">'+f+'</select>'+'</td>'+'</tr>'+'<tr>'+'<td></td>'+'<td><strong id="lbl_child1_3">Height:</strong></td>'+'<td nowrap="nowrap" width="100">'+'<select name="insured_3_heightFT" id="insured_3_heightFT">'+d+'</select>'+'<select name="insured_3_heightIN" id="insured_3_heightIN">'+e+'</select>'+'</td>'+'<td width="80" align="right"><strong id="lbl_child1_4">Weight:</strong></td>'+'<td width="190"><select name="insured_3_weight" id="insured_3_weight">'+c+'</select></td>'+'</tr>'+'<tr id="insured_3_smoker_tr" style="display:none">'+'<td></td>'+'<td><strong id="lbl_child1_5">Smoker?</strong></td>'+'<td colspan="3">'+'<input name="insured_3_smoker" id="insured_3_smoker" value="YES" type="checkbox">'+'</td>'+'</tr>'+'</table>'+'<table id="child_option1" style="display:none;" align="center" width="406" cellpadding="4" cellspacing="6" border="0">'+'<tr><td colspan="5" align="left"><strong id="lbl_child2">Child 2</strong></td></tr>'+'<tr>'+'<td width="15"></td>'+'<td width="103"><strong id="lbl_child2_1">Gender:</strong></td>'+'<td width="247" colspan="3">Male&nbsp;<input type="radio" class="radio" name="insured_4_gender" id="insured_4_gender" value="Male" />&nbsp;&nbsp;Female&nbsp;<input type="radio" class="radio" name="insured_4_gender" id="insured_4_gender2" value="Female" /></td>'+'</tr>'+'<tr>'+'<td></td>'+'<td nowrap="nowrap"><strong id="lbl_child2_2">Date of birth:</strong></td>'+'<td colspan="3"><select name="insured_4_dobMM" id="insured_4_dobMM" size="1" style="width:45px;">'+k+'</select>'+'<select name="insured_4_dobDD" id="insured_4_dobDD" size="1" style="width:45px;">'+l+'</select><select name="insured_4_dobYYYY" id="insured_4_dobYYYY" size="1" style="width:59px;" onChange="if(('+g+'-(this.value))>=18){document.getElementById(\'insured_4_smoker_tr\').style.display=display;}else{document.getElementById(\'insured_4_smoker_tr\').style.display=\'none\';}">'+f+'</select></td>'+'</tr>'+'<tr>'+'<td></td>'+'<td><strong id="lbl_child2_3">Height:</strong></td>'+'<td nowrap="nowrap" width="100"><select name="insured_4_heightFT" id="insured_4_heightFT">'+d+'</select><select name="insured_4_heightIN" id="insured_4_heightIN">'+e+'</select></td>'+'<td width="80" align="right"><strong id="lbl_child2_4">Weight:</strong></td>'+'<td width="190"><select name="insured_4_weight" id="insured_4_weight">'+c+'</select></td>'+'</tr>'+'<tr id="insured_4_smoker_tr" style="display:none">'+'<td></td>'+'<td><strong id="lbl_child2_5">Smoker?</strong></td>'+'<td colspan="3"><input name="insured_4_smoker" id="insured_4_smoker" value="YES" type="checkbox"></td>'+'</tr>'+'</table>'+'<table id="child_option2" style="display:none;" align="center" width="406" cellpadding="4" cellspacing="6" border="0">'+'<tr><td colspan="5" align="left"><strong id="lbl_child3">Child 3</strong></td></tr>'+'<tr>'+'<td width="15"></td>'+'<td width="103"><strong id="lbl_child3_1">Gender:</strong></td>'+'<td width="247" colspan="3">Male&nbsp;<input type="radio" class="radio" name="insured_5_gender" id="insured_5_gender" value="Male" />&nbsp;&nbsp;Female&nbsp;<input type="radio" class="radio" name="insured_5_gender" id="insured_5_gender2" value="Female" /></td>'+'</tr>'+'<tr>'+'<td></td>'+'<td nowrap="nowrap"><strong id="lbl_child3_2">Date of birth:</strong></td>'+'<td colspan="3"><select name="insured_5_dobMM" id="insured_5_dobMM" size="1" style="width:45px;">'+k+'</select>'+'<select name="insured_5_dobDD" id="insured_5_dobDD" size="1" style="width:45px;">'+l+'</select><select name="insured_5_dobYYYY" id="insured_5_dobYYYY" size="1" style="width:59px;" onChange="if(('+g+'-(this.value))>=18){document.getElementById(\'insured_5_smoker_tr\').style.display=display;}else{document.getElementById(\'insured_5_smoker_tr\').style.display=\'none\';}">'+f+'</select></td>'+'</tr>'+'<tr>'+'<td></td>'+'<td><strong id="lbl_child3_3">Height:</strong></td>'+'<td nowrap="nowrap" width="100"><select name="insured_5_heightFT" id="insured_5_heightFT">'+d+'</select><select name="insured_5_heightIN" id="insured_5_heightIN">'+e+'</select></td>'+'<td width="80" align="right"><strong id="lbl_child3_4">Weight:</strong></td>'+'<td width="190"><select name="insured_5_weight" id="insured_5_weight">'+c+'</select></td>'+'</tr>'+'<tr id="insured_5_smoker_tr" style="display:none">'+'<td></td>'+'<td><strong id="lbl_child3_5">Smoker?</strong></td>'+'<td colspan="3"><input name="insured_5_smoker" id="insured_5_smoker" value="YES" type="checkbox"></td>'+'</tr>'+'</table>'+'<table id="child_option3" style="display:none;" align="center" width="406" cellpadding="4" cellspacing="6" border="0">'+'<tr><td colspan="5" align="left"><strong id="lbl_child4">Child 4</strong></td></tr>'+'<tr>'+'<td width="15"></td>'+'<td width="103"><strong id="lbl_child4_1">Gender:</strong></td>'+'<td width="247" colspan="3">Male&nbsp;<input type="radio" class="radio" name="insured_6_gender" id="insured_6_gender" value="Male" />&nbsp;&nbsp;Female&nbsp;<input type="radio" class="radio" name="insured_6_gender" id="insured_6_gender2" value="Female" /></td>'+'</tr>'+'<tr>'+'<td></td>'+'<td nowrap="nowrap"><strong id="lbl_child4_2">Date of birth:</strong></td>'+'<td colspan="3"><select name="insured_6_dobMM" id="insured_6_dobMM" size="1" style="width:45px;">'+k+'</select>'+'<select name="insured_6_dobDD" id="insured_6_dobDD" size="1" style="width:45px;">'+l+'</select><select name="insured_6_dobYYYY" id="insured_6_dobYYYY" size="1" style="width:59px;" onChange="if(('+g+'-(this.value))>=18){document.getElementById(\'insured_6_smoker_tr\').style.display=display;}else{document.getElementById(\'insured_6_smoker_tr\').style.display=\'none\';}">'+f+'</select></td>'+'</tr>'+'<tr>'+'<td></td>'+'<td><strong id="lbl_child4_3">Height:</strong></td>'+'<td nowrap="nowrap" width="100"><select name="insured_6_heightFT" id="insured_6_heightFT">'+d+'</select><select name="insured_6_heightIN" id="insured_6_heightIN">'+e+'</select></td>'+'<td width="80" align="right"><strong id="lbl_child4_4">Weight:</strong></td>'+'<td width="190"><select name="insured_6_weight" id="insured_6_weight">'+c+'</select></td>'+'</tr>'+'<tr id="insured_6_smoker_tr" style="display:none">'+'<td></td>'+'<td><strong id="lbl_child4_5">Smoker?</strong></td>'+'<td colspan="3"><input name="insured_6_smoker" id="insured_6_smoker" value="YES" type="checkbox"></td>'+'</tr>'+'</table>'+'<table id="child_option4" style="display:none;" align="center" width="406" cellpadding="4" cellspacing="6" border="0">'+'<tr><td colspan="5" align="left"><strong id="lbl_child5">Child 5</strong></td></tr>'+'<tr>'+'<td width="15"></td>'+'<td width="103"><strong id="lbl_child5_1">Gender:</strong></td>'+'<td width="247" colspan="3">Male&nbsp;<input type="radio" class="radio" name="insured_7_gender" id="insured_7_gender" value="Male" />&nbsp;&nbsp;Female&nbsp;<input type="radio" class="radio" name="insured_7_gender" id="insured_7_gender2" value="Female" /></td>'+'<tr>'+'<td></td>'+'<td nowrap="nowrap"><strong id="lbl_child5_2">Date of birth:</strong></td>'+'<td colspan="3"><select name="insured_7_dobMM" id="insured_7_dobMM" size="1" style="width:45px;">'+k+'</select>'+'<select name="insured_7_dobDD" id="insured_7_dobDD" size="1" style="width:45px;">'+l+'</select><select name="insured_7_dobYYYY" id="insured_7_dobYYYY" size="1" style="width:59px;" onChange="if(('+g+'-(this.value))>=18){document.getElementById(\'insured_7_smoker_tr\').style.display=display;}else{document.getElementById(\'insured_7_smoker_tr\').style.display=\'none\';}">'+f+'</select></td>'+'</tr>'+'<tr>'+'<td></td>'+'<td><strong id="lbl_child5_3">Height:</strong></td>'+'<td nowrap="nowrap" width="100"><select name="insured_7_heightFT" id="insured_7_heightFT">'+d+'</select><select name="insured_7_heightIN" id="insured_7_heightIN">'+e+'</select></td>'+'<td width="80" align="right"><strong id="lbl_child5_4">Weight:</strong></td>'+'<td width="190"><select name="insured_7_weight" id="insured_7_weight">'+c+'</select></td>'+'</tr>'+'<tr id="insured_7_smoker_tr" style="display:none">'+'<td></td>'+'<td><strong id="lbl_child5_5">Smoker?</strong></td>'+'<td colspan="3"><input name="insured_7_smoker" id="insured_7_smoker" value="YES" type="checkbox"></td>'+'</tr>'+'</table>'+'<table id="child_option5" style="display:none;" align="center" width="406" cellpadding="4" cellspacing="6" border="0">'+'<tr><td colspan="5" align="left"><strong id="lbl_child6">Child 6</strong></td></tr>'+'<tr>'+'<td width="15"></td>'+'<td width="103"><strong id="lbl_child6_1">Gender:</strong></td>'+'<td width="247" colspan="3">Male&nbsp;<input type="radio" class="radio" name="insured_8_gender" id="insured_8_gender" value="Male" />&nbsp;&nbsp;Female&nbsp;<input type="radio" class="radio" name="insured_8_gender" id="insured_8_gender2" value="Female" /></td>'+'<tr>'+'<td></td>'+'<td nowrap="nowrap"><strong id="lbl_child6_2">Date of birth:</strong></td>'+'<td colspan="3"><select name="insured_8_dobMM" id="insured_8_dobMM" size="1" style="width:45px;">'+k+'</select>'+'<select name="insured_8_dobDD" id="insured_8_dobDD" size="1" style="width:45px;">'+l+'</select><select name="insured_8_dobYYYY" id="insured_8_dobYYYY" size="1" style="width:59px;" onChange="if(('+g+'-(this.value))>=18){document.getElementById(\'insured_8_smoker_tr\').style.display=display;}else{document.getElementById(\'insured_8_smoker_tr\').style.display=\'none\';}">'+f+'</select></td>'+'</tr>'+'<tr>'+'<td></td>'+'<td><strong id="lbl_child6_3">Height:</strong></td>'+'<td nowrap="nowrap" width="100"><select name="insured_8_heightFT" id="insured_8_heightFT">'+d+'</select><select name="insured_8_heightIN" id="insured_8_heightIN">'+e+'</select></td>'+'<td width="80" align="right"><strong id="lbl_child6_4">Weight:</strong></td>'+'<td width="190"><select name="insured_8_weight" id="insured_8_weight">'+c+'</select></td>'+'</tr>'+'<tr id="insured_8_smoker_tr" style="display:none">'+'<td></td>'+'<td><strong id="lbl_child6_5">Smoker?</strong></td>'+'<td colspan="3"><input name="insured_8_smoker" id="insured_8_smoker" value="YES" type="checkbox"></td>'+'</tr>'+'</table>'+'<div id="form-button">'+'<div align="left" style="float: left; width: 200px;">'+r+'</div><div style="padding-top: 25px;"><input type="button" value="Continue" id="button2" onclick="return chkHealthForm3(this.form);" /></div>'+'</div><div class="backbutton"><a href="#" onclick="formStepBack();">&lt;&lt; Need to go back?</a></div></div>');document.write('<div id="step4" style="display: none;">'+'<h3>Get Your Quotes</h3>'+'<div align="center" class="msg">That\'s it! Now just tell us how to reach you with your free quotes. Your information will be sent and stored securely, and we will only share it with the insurance professionals who will contact you with your quotes.</div>'+' <table align="center" width="430" cellpadding="0" cellspacing="4" border="0">'+'<tr>'+'<td nowrap="nowrap" width="79"><strong id="lbl_first_name">First name:</strong></td>'+'<td width="123"><input value="'+((o['first_name']!=undefined)?unescape(o['first_name']):"")+'" name="first_name" tabindex="1" style="width:121px;"></td>'+'<td nowrap="nowrap" align="right" width="79"><strong id="lbl_last_name">Last name:</strong></td>'+'<td width="125"><input value="'+((o['last_name']!=undefined)?unescape(o['last_name']):"")+'" name="last_name" tabindex="2" style="width:121px;"></td>'+' </tr>'+'<tr>'+'<td align="right"><strong id="lbl_address">Address:</strong></td>'+'<td><input value="'+((o['address_1_street1']!=undefined)?unescape(o['address_1_street1']):"")+'" name="address_1_street1" tabindex="3" style="width:121px;"></td>'+'<td align="right"><strong id="lbl_city">City:</strong></td>'+'<td><input value="'+((o['address_1_city']!=undefined)?unescape(o['address_1_city']):"")+'" name="address_1_city" tabindex="4" style="width:121px;"></td>'+'</tr>'+'<tr>'+'<td align="right"><strong id="lbl_state">State:</strong></td>'+'<td><select name="address_1_state" tabindex="5" style="width:122px;">'+'<option value="" selected></option><option value="AL">Alabama</option><option value="AK">Alaska</option><option value="AZ">Arizona</option><option value="AR">Arkansas</option><option value="CA">California</option><option value="CO">Colorado</option><option value="CT">Connecticut</option><option value="DE">Delaware</option><option value="DC">Dist. of Columbia</option><option value="FL">Florida</option><option value="GA">Georgia</option><option value="HI">Hawaii</option><option value="ID">Idaho</option><option value="IL">Illinois</option><option value="IN">Indiana</option><option value="IA">Iowa</option><option value="KS">Kansas</option><option value="KY">Kentucky</option><option value="LA">Louisiana</option><option value="ME">Maine</option><option value="MD">Maryland</option><option value="MA">Massachusetts</option><option value="MI">Michigan</option><option value="MN">Minnesota</option><option value="MS">Mississippi</option><option value="MO">Missouri</option><option value="MT">Montana</option><option value="NE">Nebraska</option><option value="NV">Nevada</option><option value="NH">New Hampshire</option><option value="NJ">New Jersey</option><option value="NM">New Mexico</option><option value="NY">New York</option><option value="NC">North Carolina</option><option value="ND">North Dakota</option><option value="OH">Ohio</option><option value="OK">Oklahoma</option><option value="OR">Oregon</option><option value="PA">Pennsylvania</option><option value="RI">Rhode Island</option><option value="SC">South Carolina</option><option value="SD">South Dakota</option><option value="TN">Tennessee</option><option value="TX">Texas</option><option value="UT">Utah</option><option value="VT">Vermont</option><option value="VA">Virginia</option><option value="WA">Washington</option><option value="WV">West Virginia</option><option value="WI">Wisconsin</option><option value="WY">Wyoming</option>'+'</select></td>'+'<td align="right"><strong id="lbl_zip">Zip:</strong></td>'+'<td><input value="'+((o['address_1_zip']!=undefined)?o['address_1_zip']:"")+'" name="address_1_zip" id="address_1_zip" maxlength="5" style="width:40px;" tabindex="6"></td>'+'</tr>'+'<tr>'+'<td align="right"><strong id="lbl_phone">Phone:</strong></td>'+'<td>(<input name="phone_1" id="phone_1" style="width:22px;" tabindex="7" onKeyUp="if(this.value.length==3 && !isNaN(this.value)){document.getElementById(\'phone_2\').focus();}" value="" maxlength="3" />) <input name="phone_2" id="phone_2" style="width:22px;" tabindex="8" onKeyUp="if(this.value.length==3 && !isNaN(this.value)){document.getElementById(\'phone_3\').focus();}" value="" maxlength="3" /> - <input name="phone_3" id="phone_3" style="width:30px;" tabindex="9" onKeyUp="if(this.value.length==4 && !isNaN(this.value)){document.getElementById(\'email\').focus();}" value="" maxlength="4" /><input name="phone" id="phone" style="width:190px;display:none;"></td>'+'<td align="right"><strong id="lbl_email">Email:</strong></td>'+'<td><input value="'+((o['email']!=undefined)?unescape(o['email']):"")+'" name="email" id="email" tabindex="10" style="width:121px;" maxlength="55"></td>'+'</tr>'+'</table>'+'<div id="form-button">'+'<div align="center" style="float: left; width: 200px; text-align: center;">'+r+'</div><div style="padding-top: 23px;"><input type="button" value="Get Quotes" id="button2" onclick="return chkHealthForm4(this.form);" /></div></div>'+'<div class="backbutton"><a href="#" onclick="formStepBack();">&lt;&lt; Need to go back?</a></div></div>');document.write('<br /><div align="left"></div></form></div></div><div align="left" class="disclaimer"><p><a href="javascript:makePopUp(\''+n+'privacy-policy.html\', 502, 750)">Privacy Policy</a> | <a href="javascript:makePopUp(\''+n+'terms.html\', 502, 750)">Terms and Conditions</a>&nbsp;&nbsp;&nbsp;Copyright &copy; 2007 InsureLane | 1-888-250-3253<br />The InsureLane Network is made up of independent agents representing over 40 of the leading private insurance companies. Please note that this is <strong>not</strong> an application or enrollment form for public or government-sponsored health care. </p></div></div>');