	<script type="text/javascript">
	var spouseflag= new Boolean(false)
	var child1flag= new Boolean(false)
	var child2flag= new Boolean(false)
	var child3flag= new Boolean(false)
	var child4flag= new Boolean(false)
	var child5flag= new Boolean(false)
	var currentlyinsuredflag= new Boolean(false)
	var Lcurrentlyinsuredflag= new Boolean(false)

	function validate()
	{
		var valid_flag=new Boolean(true)
		var family_flag=new Boolean(true)


		var source1=new Boolean(check_source())
		if(source1==false){
                        document.getElementById("endli").className="error"
			document.getElementById("source").focus();
			document.getElementById("ctact").innerHTML="How Did You Hear About Us?<font color=\"red\">*</font>"
                        valid_flag=false
		}
		else{
			document.getElementById("ctact").innerHTML="How Did You Hear About Us?"
		}

		var fn=new Boolean(check_name(document.getElementById("FirstName").value))
		var ln=new Boolean(check_name(document.getElementById("LastName").value))

		var dp=new Boolean(check_phone(document.getElementById("DayPhoneAC").value,document.getElementById("DayPhone1").value,document.getElementById("DayPhone2").value))
		var ea=new Boolean(check_email(document.getElementById("Email").value))

		var a1=new Boolean(check_name(document.getElementById("StreetAddress").value))
		var city=new Boolean(check_name(document.getElementById("City").value))
		var zip=new Boolean(check_zip(document.getElementById("ZipCode").value))

		if(fn==false){
			document.getElementById("FirstName").focus();
			document.getElementById("fname").innerHTML="First Name <font color=\"red\">*</font>"
		}
		else{
			document.getElementById("fname").innerHTML="First Name"
		}
		if(ln==false){
			document.getElementById("LastName").focus();
			document.getElementById("lname").innerHTML="Last Name <font color=\"red\">*</font>"
		}
		else{
			document.getElementById("lname").innerHTML="Last Name"
		}
		if(fn==false || ln==false ){
			document.getElementById("nameli").className="error"
			valid_flag=false
		}
		else{
			document.getElementById("nameli").className=""
		}

		if(dp==false){
			document.getElementById("DayPhoneAC").focus();
			document.getElementById("dphone").innerHTML="Daytime Phone <font color=\"red\">*</font>"
		}
		else{
			document.getElementById("dphone").innerHTML="Daytime Phone"
		}
		if(ea==false){
			document.getElementById("Email").focus();
			document.getElementById("eml").innerHTML="E-Mail Address<font color=\"red\">*</font>"
		}
		else{
			document.getElementById("eml").innerHTML="E-Mail Address"
		}

		if(dp==false || ea==false ){
			document.getElementById("contactli").className="error"
			valid_flag=false
		}
		else{
			document.getElementById("contactli").className=""
		}

		if(a1==false){
			document.getElementById("StreetAddress").focus();
			document.getElementById("saddress1").innerHTML="Street Address<font color=\"red\">*</font>"
		}
		else{
			document.getElementById("saddress1").innerHTML="Street Address"
		}
		if(city==false){
			document.getElementById("City").focus();
			document.getElementById("city1").innerHTML="City<font color=\"red\">*</font>"
		}
		else{
			document.getElementById("city1").innerHTML="City"
		}

		var st1=new Boolean(check_state())
		if(st1==false){
			document.getElementById("state1").focus();
			document.getElementById("state1").innerHTML="State<font color=\"red\">*</font>"
		}
		else{
			document.getElementById("state1").innerHTML="State"
		}

		if(zip==false){
			document.getElementById("ZipCode").focus();
			document.getElementById("zipcode1").innerHTML="Zip Code<font color=\"red\">*</font>"
		}
		else{
			document.getElementById("zipcode1").innerHTML="Zip Code"
		}
		if(a1==false || city==false || zip==false || st1==false){
			document.getElementById("addressli").className="error";
			valid_flag=false
		}
		else{
			document.getElementById("addressli").className=""
		}

		var qt1=new Boolean(check_qtype())
		if(qt1==false){
			document.getElementById("currentinfoli").className="error";
document.getElementById("QuoteType").innerHTML="Is this quote for Health, Life, or Both?<font color=\"red\">*</font>";
                        $cili="error"
		}
		else{
		document.getElementById("QuoteType").innerHTML="Is this quote for Health, Life, or Both?";
		}

		var ms1=new Boolean(check_mstatus())
		if(ms1==false){
			document.getElementById("mstatus").focus();
			document.getElementById("mstatus").innerHTML="Marital Status<font color=\"red\">*</font>"
		}
		else{
			document.getElementById("mstatus").innerHTML="Marital Status"
		}
		var es1=new Boolean(check_estatus())
		if(es1==false){
			document.getElementById("estatus").focus();
			document.getElementById("estatus").innerHTML="Employment Status<font color=\"red\">*</font>"
		}
		else{
			document.getElementById("estatus").innerHTML="Employment Status"
		}
		var rs1=new Boolean(check_rstatus())
		if(rs1==false){
			document.getElementById("rstatus").focus();
			document.getElementById("rstatus").innerHTML="Residential Status<font color=\"red\">*</font>"
		}
		else{
			document.getElementById("rstatus").innerHTML="Residential Status"
		}
		if(ms1==false || es1==false || rs1==false){
			document.getElementById("pstatusli").className="error"
			valid_flag=false
		}
		else{
			document.getElementById("pstatusli").className=""
		}



		if(currentlyinsuredflag==true){
			var carrier=new Boolean(check_name(document.getElementById("Carrier").value))
			var mp=new Boolean(check_name(document.getElementById("MonthlyPremium").value))

			if(carrier==false){
				document.getElementById("Carrier").focus();
				document.getElementById("cname").innerHTML="If so, which carrier?<font color=\"red\">*</font>"
			}
			else{
				document.getElementById("cname").innerHTML="If so, which carrier?"
			}
			if(mp==false){
				document.getElementById("MonthlyPremium").focus();
				document.getElementById("mpremium").innerHTML="Monthly Premium<font color=\"red\">*</font>"
			}
			else{
				document.getElementById("mpremium").innerHTML="Monthly Premium"
			}
			if(carrier==false || mp==false ){
				document.getElementById("currentinfoli").className="error"
				valid_flag=false
			}
			else{
				document.getElementById("currentinfoli").className=""
			}
		}
		else{
			document.getElementById("cname").innerHTML="If so, which carrier?"
			document.getElementById("mpremium").innerHTML="Monthly Premium"
			document.getElementById("currentinfoli").className=""
		}

		if(checkWeight(document.getElementById("AWeight").value)==false){
			document.getElementById("aname").innerHTML="<font color=\"red\">Applicant</font>"
			document.getElementById("AWeight").focus();
			valid_flag=false
			family_flag=false
		}
		else if(checkDD(document.getElementById("AHeight").value)==false){
			document.getElementById("aname").innerHTML="<font color=\"red\">Applicant</font>"
			document.getElementById("AHeight").focus();
			valid_flag=false
			family_flag=false
		}
		else if(checkDD(document.getElementById("Ayyyy").value)==false){
			document.getElementById("aname").innerHTML="<font color=\"red\">Applicant</font>"
			document.getElementById("Ayyyy").focus();
			valid_flag=false
			family_flag=false
		}
		else if(checkDD(document.getElementById("Add").value)==false){
			document.getElementById("aname").innerHTML="<font color=\"red\">Applicant</font>"
			document.getElementById("Add").focus();
			valid_flag=false
			family_flag=false
		}
		else if(checkDD(document.getElementById("Amm").value)==false){
			document.getElementById("aname").innerHTML="<font color=\"red\">Applicant</font>"
			document.getElementById("Amm").focus();
			valid_flag=false
			family_flag=false
		}
		else{
			document.getElementById("aname").innerHTML="Applicant"
		}
		if(spouseflag==true){
			if(checkWeight(document.getElementById("SWeight").value)==false){
				document.getElementById("sname").innerHTML="<font color=\"red\">Spouse</font>"
				document.getElementById("SWeight").focus();
				valid_flag=false
				family_flag=false
			}
			else if(checkDD(document.getElementById("SHeight").value)==false){
				document.getElementById("sname").innerHTML="<font color=\"red\">Spouse</font>"
				document.getElementById("SHeight").focus();
				valid_flag=false
				family_flag=false
			}
			else if(checkDD(document.getElementById("Syyyy").value)==false){
				document.getElementById("sname").innerHTML="<font color=\"red\">Spouse</font>"
				document.getElementById("Syyyy").focus();
				valid_flag=false
				family_flag=false
			}
			else if(checkDD(document.getElementById("Sdd").value)==false){
				document.getElementById("sname").innerHTML="<font color=\"red\">Spouse</font>"
				document.getElementById("Sdd").focus();
				valid_flag=false
				family_flag=false
			}
			else if(checkDD(document.getElementById("Smm").value)==false){
				document.getElementById("sname").innerHTML="<font color=\"red\">Spouse</font>"
				document.getElementById("Smm").focus();
				valid_flag=false
				family_flag=false
			}
			else{
				document.getElementById("sname").innerHTML="Spouse"
			}
		}
		else{
			document.getElementById("sname").innerHTML="Spouse"
		}
		if(child1flag==true){
			if(checkWeight(document.getElementById("C1Weight").value)==false){
				document.getElementById("c1name").innerHTML="<font color=\"red\">Child #1</font>"
				document.getElementById("C1Weight").focus();
				valid_flag=false
				family_flag=false
			}
			else if(checkDD(document.getElementById("C1Height").value)==false){
				document.getElementById("c1name").innerHTML="<font color=\"red\">Child #1</font>"
				document.getElementById("C1Height").focus();
				valid_flag=false
				family_flag=false
			}
			else if(checkDD(document.getElementById("C1yyyy").value)==false){
				document.getElementById("c1name").innerHTML="<font color=\"red\">Child #1</font>"
				document.getElementById("C1yyyy").focus();
				valid_flag=false
				family_flag=false
			}
			else if(checkDD(document.getElementById("C1dd").value)==false){
				document.getElementById("c1name").innerHTML="<font color=\"red\">Child #1</font>"
				document.getElementById("C1dd").focus();
				valid_flag=false
				family_flag=false
			}
			else if(checkDD(document.getElementById("C1mm").value)==false){
				document.getElementById("c1name").innerHTML="<font color=\"red\">Child #1</font>"
				document.getElementById("C1mm").focus();
				valid_flag=false
				family_flag=false
			}
			else{
				document.getElementById("c1name").innerHTML="Child #1"
			}
		}
		else{
			document.getElementById("c1name").innerHTML="Child #1"
		}
		if(child2flag==true){
			if(checkWeight(document.getElementById("C2Weight").value)==false){
				document.getElementById("c2name").innerHTML="<font color=\"red\">Child #2</font>"
				document.getElementById("C2Weight").focus();
				valid_flag=false
				family_flag=false
			}
			else if(checkDD(document.getElementById("C2Height").value)==false){
				document.getElementById("c2name").innerHTML="<font color=\"red\">Child #2</font>"
				document.getElementById("C2Height").focus();
				valid_flag=false
				family_flag=false
			}
			else if(checkDD(document.getElementById("C2yyyy").value)==false){
				document.getElementById("c2name").innerHTML="<font color=\"red\">Child #2</font>"
				document.getElementById("C2yyyy").focus();
				valid_flag=false
				family_flag=false
			}
			else if(checkDD(document.getElementById("C2dd").value)==false){
				document.getElementById("c2name").innerHTML="<font color=\"red\">Child #2</font>"
				document.getElementById("C2dd").focus();
				valid_flag=false
				family_flag=false
			}
			else if(checkDD(document.getElementById("C2mm").value)==false){
				document.getElementById("c2name").innerHTML="<font color=\"red\">Child #2</font>"
				document.getElementById("C2mm").focus();
				valid_flag=false
				family_flag=false
			}
			else{
				document.getElementById("c2name").innerHTML="Child #2"
			}
		}
		else{
			document.getElementById("c2name").innerHTML="Child #2"
		}
		if(child3flag==true){
			if(checkWeight(document.getElementById("C3Weight").value)==false){
				document.getElementById("c3name").innerHTML="<font color=\"red\">Child #3</font>"
				document.getElementById("C3Weight").focus();
				valid_flag=false
				family_flag=false
			}
			else if(checkDD(document.getElementById("C3Height").value)==false){
				document.getElementById("c3name").innerHTML="<font color=\"red\">Child #3</font>"
				document.getElementById("C3Height").focus();
				valid_flag=false
				family_flag=false
			}
			else if(checkDD(document.getElementById("C3yyyy").value)==false){
				document.getElementById("c3name").innerHTML="<font color=\"red\">Child #3</font>"
				document.getElementById("C3yyyy").focus();
				valid_flag=false
				family_flag=false
			}
			else if(checkDD(document.getElementById("C3dd").value)==false){
				document.getElementById("c3name").innerHTML="<font color=\"red\">Child #3</font>"
				document.getElementById("C3dd").focus();
				valid_flag=false
				family_flag=false
			}
			else if(checkDD(document.getElementById("C3mm").value)==false){
				document.getElementById("c3name").innerHTML="<font color=\"red\">Child #3</font>"
				document.getElementById("C3mm").focus();
				valid_flag=false
				family_flag=false
			}
			else{
				document.getElementById("c3name").innerHTML="Child #3"
			}
		}
		else{
			document.getElementById("c3name").innerHTML="Child #3"
		}
		if(child4flag==true){
			if(checkWeight(document.getElementById("C4Weight").value)==false){
				document.getElementById("c4name").innerHTML="<font color=\"red\">Child #4</font>"
				document.getElementById("C4Weight").focus();
				valid_flag=false
				family_flag=false
			}
			else if(checkDD(document.getElementById("C4Height").value)==false){
				document.getElementById("c4name").innerHTML="<font color=\"red\">Child #4</font>"
				document.getElementById("C4Height").focus();
				valid_flag=false
				family_flag=false
			}
			else if(checkDD(document.getElementById("C4yyyy").value)==false){
				document.getElementById("c4name").innerHTML="<font color=\"red\">Child #4</font>"
				document.getElementById("C4yyyy").focus();
				valid_flag=false
				family_flag=false
			}
			else if(checkDD(document.getElementById("C4dd").value)==false){
				document.getElementById("c4name").innerHTML="<font color=\"red\">Child #4</font>"
				document.getElementById("C4dd").focus();
				valid_flag=false
				family_flag=false
			}
			else if(checkDD(document.getElementById("C4mm").value)==false){
				document.getElementById("c4name").innerHTML="<font color=\"red\">Child #4</font>"
				document.getElementById("C4mm").focus();
				valid_flag=false
				family_flag=false
			}
			else{
				document.getElementById("c4name").innerHTML="Child #4"
			}
		}
		else{
			document.getElementById("c4name").innerHTML="Child #4"
		}
		if(child5flag==true){
			if(checkWeight(document.getElementById("C5Weight").value)==false){
				document.getElementById("c5name").innerHTML="<font color=\"red\">Child #5</font>"
				document.getElementById("C5Weight").focus();
				valid_flag=false
				family_flag=false
			}
			else if(checkDD(document.getElementById("C5Height").value)==false){
				document.getElementById("c5name").innerHTML="<font color=\"red\">Child #5</font>"
				document.getElementById("C5Height").focus();
				valid_flag=false
				family_flag=false
			}
			else if(checkDD(document.getElementById("C5yyyy").value)==false){
				document.getElementById("c5name").innerHTML="<font color=\"red\">Child #5</font>"
				document.getElementById("C5yyyy").focus();
				valid_flag=false
				family_flag=false
			}
			else if(checkDD(document.getElementById("C5dd").value)==false){
				document.getElementById("c5name").innerHTML="<font color=\"red\">Child #5</font>"
				document.getElementById("C5dd").focus();
				valid_flag=false
				family_flag=false
			}
			else if(checkDD(document.getElementById("C5mm").value)==false){
				document.getElementById("c5name").innerHTML="<font color=\"red\">Child #5</font>"
				document.getElementById("C5mm").focus();
				valid_flag=false
				family_flag=false
			}
			else{
				document.getElementById("c5name").innerHTML="Child #5"
			}
		}
		else{
			document.getElementById("c5name").innerHTML="Child #5"
		}

		if(family_flag==false){
			document.getElementById("familyli").className="error"
		}
		else{
			document.getElementById("familyli").className=""
		}

		if(valid_flag==false){
			document.getElementById("ftr").innerHTML="<font color=\"red\">*Required field(s) invalid<br />Please ensure the above information is correct.</font>"
		}
		else{
			document.getElementById("ftr").innerHTML=""
		}

		return valid_flag
	}

	function check_source()
	{
		if(document.getElementById("source").value=="0"){
			return false
		}
		return true
	}

	function check_name(str)
	{
		if(str==null || str==""){
			return false
		}
		return true
	}
	function check_email(str) 
	{
		if(/^\w+([\.-]?\w+)*@\w+([\.-]?\w+)*(\.\w{2,3})+$/.test(str)){
			return true
		}
		return false
	}
	function check_zip(num)
	{
		if(/^[0-9][0-9][0-9][0-9][0-9]$/.test(num)){
			return true
		}
		return false
	}
	function check_phone(ac,num1,num2)
	{
		if( (/^[0-9][0-9][0-9]$/.test(ac)) && (/^[0-9][0-9][0-9]$/.test(num1)) && (/^[0-9][0-9][0-9][0-9]$/.test(num2)) ){
			return true
		}
		return false
	}
	function checkCurrent()
	{
		if(document.getElementById("CurrentlyInsured").value=="yes"){
			currentlyinsuredflag=true
			document.getElementById("Carrier").disabled=false
			document.getElementById("MonthlyPremium").disabled=false
			document.getElementById("EmployerPays").disabled=false
		}
		else{
			currentlyinsuredflag=false
			document.getElementById("Carrier").disabled=true
			document.getElementById("MonthlyPremium").disabled=true
			document.getElementById("EmployerPays").disabled=true
			document.getElementById("cname").innerHTML="If so, which carrier?"
			document.getElementById("mpremium").innerHTML="Monthly Premium"
		}
	}
	function LcheckCurrent()
	{
		if(document.getElementById("LCurrentlyInsured").value=="yes"){
			Lcurrentlyinsuredflag=true
			document.getElementById("LCarrier").disabled=false
			document.getElementById("LMonthlyPremium").disabled=false
			document.getElementById("LEmployerPays").disabled=false
		}
		else{
			Lcurrentlyinsuredflag=false
			document.getElementById("LCarrier").disabled=true
			document.getElementById("LMonthlyPremium").disabled=true
			document.getElementById("LEmployerPays").disabled=true
			document.getElementById("Lcname").innerHTML="If so, which carrier?"
			document.getElementById("Lmpremium").innerHTML="Monthly Premium"
		}
	}

	function checkWeight(num)
	{
		if(/^[0-9][0-9]?[0-9]?$/.test(num)){
			return true
		}
		return false
	}
	function checkDD(index)
	{
		if(index=="-1"){
			return false
		}
		return true
	}
	function spouse()
	{
		if(document.getElementById("SGender").value!="0"){
			spouseflag=true
			document.getElementById("Smm").disabled=false
			document.getElementById("Sdd").disabled=false
			document.getElementById("Syyyy").disabled=false
			document.getElementById("SHeight").disabled=false
			document.getElementById("SWeight").disabled=false
			document.getElementById("STUser").disabled=false
		}
		else{
			spouseflag=false
			document.getElementById("Smm").disabled=true
			document.getElementById("Sdd").disabled=true
			document.getElementById("Syyyy").disabled=true
			document.getElementById("SHeight").disabled=true
			document.getElementById("SWeight").disabled=true
			document.getElementById("STUser").disabled=true
			document.getElementById("sname").innerHTML="Spouse"
		}
	}
	function child1()
	{
		if(document.getElementById("C1Gender").value!="0"){
			child1flag=true
			document.getElementById("C1mm").disabled=false
			document.getElementById("C1dd").disabled=false
			document.getElementById("C1yyyy").disabled=false
			document.getElementById("C1Height").disabled=false
			document.getElementById("C1Weight").disabled=false
			document.getElementById("C1TUser").disabled=false
		}
		else{
			child1flag=false
			document.getElementById("C1mm").disabled=true
			document.getElementById("C1dd").disabled=true
			document.getElementById("C1yyyy").disabled=true
			document.getElementById("C1Height").disabled=true
			document.getElementById("C1Weight").disabled=true
			document.getElementById("C1TUser").disabled=true
			document.getElementById("c1name").innerHTML="Child #1"
		}
	}
	function child2()
	{
		if(document.getElementById("C2Gender").value!="0"){
			child2flag=true
			document.getElementById("C2mm").disabled=false
			document.getElementById("C2dd").disabled=false
			document.getElementById("C2yyyy").disabled=false
			document.getElementById("C2Height").disabled=false
			document.getElementById("C2Weight").disabled=false
			document.getElementById("C2TUser").disabled=false
		}
		else{
			child2flag=false
			document.getElementById("C2mm").disabled=true
			document.getElementById("C2dd").disabled=true
			document.getElementById("C2yyyy").disabled=true
			document.getElementById("C2Height").disabled=true
			document.getElementById("C2Weight").disabled=true
			document.getElementById("C2TUser").disabled=true
			document.getElementById("c2name").innerHTML="Child #2"
		}
	}
	function child3()
	{
		if(document.getElementById("C3Gender").value!="0"){
			child3flag=true
			document.getElementById("C3mm").disabled=false
			document.getElementById("C3dd").disabled=false
			document.getElementById("C3yyyy").disabled=false
			document.getElementById("C3Height").disabled=false
			document.getElementById("C3Weight").disabled=false
			document.getElementById("C3TUser").disabled=false
		}
		else{
			child3flag=false
			document.getElementById("C3mm").disabled=true
			document.getElementById("C3dd").disabled=true
			document.getElementById("C3yyyy").disabled=true
			document.getElementById("C3Height").disabled=true
			document.getElementById("C3Weight").disabled=true
			document.getElementById("C3TUser").disabled=true
			document.getElementById("c3name").innerHTML="Child #3"
		}
	}
	function child4()
	{
		if(document.getElementById("C4Gender").value!="0"){
			child4flag=true
			document.getElementById("C4mm").disabled=false
			document.getElementById("C4dd").disabled=false
			document.getElementById("C4yyyy").disabled=false
			document.getElementById("C4Height").disabled=false
			document.getElementById("C4Weight").disabled=false
			document.getElementById("C4TUser").disabled=false
		}
		else{
			child4flag=false
			document.getElementById("C4mm").disabled=true
			document.getElementById("C4dd").disabled=true
			document.getElementById("C4yyyy").disabled=true
			document.getElementById("C4Height").disabled=true
			document.getElementById("C4Weight").disabled=true
			document.getElementById("C4TUser").disabled=true
			document.getElementById("c4name").innerHTML="Child #4"
		}
	}
	function child5()
	{
		if(document.getElementById("C5Gender").value!="0"){
			child5flag=true
			document.getElementById("C5mm").disabled=false
			document.getElementById("C5dd").disabled=false
			document.getElementById("C5yyyy").disabled=false
			document.getElementById("C5Height").disabled=false
			document.getElementById("C5Weight").disabled=false
			document.getElementById("C5TUser").disabled=false
		}
		else{
			child5flag=false
			document.getElementById("C5mm").disabled=true
			document.getElementById("C5dd").disabled=true
			document.getElementById("C5yyyy").disabled=true
			document.getElementById("C5Height").disabled=true
			document.getElementById("C5Weight").disabled=true
			document.getElementById("C5TUser").disabled=true
			document.getElementById("c5name").innerHTML="Child #5"
		}
	}
	function check_state()
	{
		if(document.getElementById("State").value=="0" || document.getElementById("State").value=="1"){
			return false
		}
		return true
	}
	function check_qtype()
	{
		if(document.getElementById("QuoteType").value=="0"){
			return false
		}
		return true
	}
	function check_mstatus()
	{
		if(document.getElementById("MaritalStatus").value=="0" || document.getElementById("MaritalStatus").value=="1"){
			return false
		}
		return true
	}
	function check_estatus()
	{
		if(document.getElementById("EmploymentStatus").value=="0" || document.getElementById("EmploymentStatus").value=="1"){
			return false
		}
		return true
	}
	function check_rstatus()
	{
		if(document.getElementById("Residence").value=="0" || document.getElementById("Residence").value=="1"){
			return false
		}
		return true
	}

	</script>
