";
}
if (document.frm.InsuranceType.value == "Life Insurance")
{
//New Fields For HTQ
data="Tell us about your current situation: Is any applicant a smoker? * --Select-- Yes No Have you been rated or declined for health or life insurance in the last 5 years? * Have you been hospitalized in the last 5 years? * Have you had a DUI/DWI in the last 5 years? * Have you been a resident of the U.S. or Canada for the last 12 months? * Do you currently take prescription medications? * If yes, please list medication names and dosages: * Do you currently have a life insurance? * --Select-- Yes No If so, with what company? * ";
data = data + "";
data = data + "--Select-- ";
data = data + "";
data = data + "AAA ";
data = data + "AIG ";
data = data + "Allied ";
data = data + "Allstate ";
data = data + "American Family ";
data = data + "Amica ";
data = data + "Farm Bureau ";
data = data + "Farmers ";
data = data + "GEICO ";
data = data + "Hartford "
data = data + "Liberty Mutual ";
data = data + "Metropolitan Co. ";
data = data + "Nationwide ";
data = data + "Progressive ";
data = data + "Prudential ";
data = data + "SAFECO ";
data = data + "State Farm ";
data = data + "Travelers ";
data = data + "United Services Automobile Association ";
data = data + "Unitrin Direct ";
data = data + "Other Company (Not Listed) ";
data = data + "";
data = data + "";
data = data + "";
data = data + "Other Company (Not Listed) ";
data = data + "AAA ";
data = data + "AABCO ";
data = data + "Acceptance ";
data = data + "Access Insurance ";
data = data + "Acordia ";
data = data + "Aegis Security ";
data = data + "AETNA ";
data = data + "Affirmative ";
data = data + "AIG ";
data = data + "AIU ";
data = data + "Alliance for Affordable Services ";
data = data + "Allied ";
data = data + "All Nation ";
data = data + "All Risk ";
data = data + "Allianz ";
data = data + "Allstate ";
data = data + "Amalgamated Life Insurance ";
data = data + "AMCO ";
data = data + "America's Ins. Consultants ";
data = data + "American Alliance ";
data = data + "American Banks ";
data = data + "American Economy ";
data = data + "American Empire Group ";
data = data + "American Family ";
data = data + "American General ";
data = data + "American International Group ";
data = data + "American Investors ";
data = data + "American National ";
data = data + "American Premier ";
data = data + "American Reliable ";
data = data + "American Republic ";
data = data + "American Standard ";
data = data + "American States ";
data = data + "American Sterling Insurance ";
data = data + "American Underwriters ";
data = data + "American United Life Insurance ";
data = data + "Amerisure ";
data = data + "AmerUs Life ";
data = data + "AmwestInsurance Group ";
data = data + "Amica ";
data = data + "API ";
data = data + "Arbella ";
data = data + "Arizona General ";
data = data + "Assigned Risk ";
data = data + "Association Field Services ";
data = data + "Associated Indemnity ";
data = data + "Assurity LIfe ";
data = data + "Atlanta Casualty ";
data = data + "Atlantic Indemnity ";
data = data + "Austin Mutual ";
data = data + "Auto Owners ";
data = data + "Avomark ";
data = data + "Badger Mutual ";
data = data + "Bankers & Shippers ";
data = data + "Bankers Life and Casualty ";
data = data + "Beneficial Life Insurance ";
data = data + "Berkshire Life Insurance ";
data = data + "Blue Cross/Blue Shield ";
data = data + "Bonneville ";
data = data + "Boston Old Colony ";
data = data + "Builders ";
data = data + "Cal Farm ";
data = data + "California Casualty ";
data = data + "California State Automobile Association ";
data = data + "Camden ";
data = data + "Capital Choice ";
data = data + "Care Entrie ";
data = data + "Cascade National Ins ";
data = data + "Casualty Assurance ";
data = data + "Centennial ";
data = data + "Charter Oak ";
data = data + "Chicago Insurance ";
data = data + "Chubb ";
data = data + "church Mutual ";
data = data + "Cigna ";
data = data + "Citizens ";
data = data + "Clarendon American ";
data = data + "Cloverleaf ";
data = data + "CMA ";
data = data + "CMA Alliance ";
data = data + "CNA ";
data = data + "Colonial ";
data = data + "Combined ";
data = data + "Commercial Union ";
data = data + "Commonwealth ";
data = data + "Continental ";
data = data + "Cotton States ";
data = data + "Cottonwood ";
data = data + "Country Financial Services ";
data = data + "Country Insurance ";
data = data + "Credit Union ";
data = data + "Criterion ";
data = data + "CUNA Mutual ";
data = data + "Dairyland ";
data = data + "Dakota Fire ";
data = data + "Deerbrook ";
data = data + "Depositors Emcasc ";
data = data + "Dixie ";
data = data + "Ebco General ";
data = data + "Economy ";
data = data + "Electric ";
data = data + "EMC ";
data = data + "Empire ";
data = data + "Employers Fire ";
data = data + "Ensure ";
data = data + "Equitable ";
data = data + "Erie Insurance ";
data = data + "Facility ";
data = data + "Farm Bureau ";
data = data + "Farmers ";
data = data + "Farmland ";
data = data + "Federal ";
data = data + "Federated ";
data = data + "Fidelity ";
data = data + "Financial Indemnity ";
data = data + "Fire and Casualty Co of CT ";
data = data + "Fireman's Fund ";
data = data + "First American ";
data = data + "First Colony ";
data = data + "First Financial ";
data = data + "First General ";
data = data + "First National ";
data = data + "Ford Motor Credit ";
data = data + "Foremost ";
data = data + "Fortis Group ";
data = data + "Franklin ";
data = data + "Golden Rule ";
data = data + "GEICO ";
data = data + "GE Financial Network ";
data = data + "General Accident ";
data = data + "Gerber Life Insurance ";
data = data + "Globe ";
data = data + "GMAC ";
data = data + "Golden Rule ";
data = data + "Government Employees ";
data = data + "Grange ";
data = data + "GRE ";
data = data + "Great American ";
data = data + "Great Way ";
data = data + "Great West ";
data = data + "Grinnell Mutual ";
data = data + "Guaranty National ";
data = data + "Guardian ";
data = data + "Guide One ";
data = data + "GEICO ";
data = data + "Halcyon ";
data = data + "Hanover Lloyd's Company ";
data = data + "Happy Days ";
data = data + "Hartford ";
data = data + "Hawkeye Security ";
data = data + "Health Net ";
data = data + "Health Plus of America ";
data = data + "Heritage ";
data = data + "Horace Mann ";
data = data + "Humana ";
data = data + "IDS ";
data = data + "IFA Auto ";
data = data + "IGF ";
data = data + "Infinity ";
data = data + "Insurance of Evanston ";
data = data + "Integon ";
data = data + "Interstatey ";
data = data + "John Deere ";
data = data + "John Hancock ";
data = data + "Kaiser Foundation Health Plan ";
data = data + "Kemper Lloyds ";
data = data + "Kemper Insurance ";
data = data + "Kentucky Central ";
data = data + "Landmark American ";
data = data + "Landmark Life Insurance ";
data = data + "Leader General ";
data = data + "Leader National ";
data = data + "League General ";
data = data + "Liberty Mutual ";
data = data + "Lincoln Financial Group ";
data = data + "London Life Insurance ";
data = data + "Lumbermens Mutual ";
data = data + "Managed Comp ";
data = data + "Marathon ";
data = data + "Markel American ";
data = data + "Maryland Casualty ";
data = data + "Mass Mutual ";
data = data + "MBA Insurance ";
data = data + "Mendota ";
data = data + "Mega Life and Health Ins. ";
data = data + "Merastar ";
data = data + "Mercury ";
data = data + "Met Life ";
data = data + "Metropolitan Co. ";
data = data + "Mid Century ";
data = data + "Mid-Continent Casualty ";
data = data + "MidWest Mutual ";
data = data + "Mid-West Ntl. Life ";
data = data + "MidCentury (Farmers) ";
data = data + "Midwest Mutual ";
data = data + "Middlesex ";
data = data + "Millbank ";
data = data + "Millers Mutual ";
data = data + "Milwaukee ";
data = data + "Milwaukee Guardian ";
data = data + "Milwaukee Mutual ";
data = data + "Minnehoma ";
data = data + "Missouri General ";
data = data + "Modern Woodmen of America ";
data = data + "MONY Group ";
data = data + "Motors ";
data = data + "Mountain Laurel ";
data = data + "MSI ";
data = data + "Mutual of Enumclaw ";
data = data + "Mutual of New York ";
data = data + "Mutual Of Omaha ";
data = data + "N.A.S.E. ";
data = data + "National Alliance ";
data = data + "National Assoc - Self Employed ";
data = data + "National Colonial ";
data = data + "National Continental ";
data = data + "National Farmers Union ";
data = data + "National Health ";
data = data + "National Indemnity ";
data = data + "National Merit ";
data = data + "National Surety Corp ";
data = data + "Nationwide ";
data = data + "New England Financial ";
data = data + "New York Life ";
data = data + "North American ";
data = data + "North Pacific ";
data = data + "Northe Pointe ";
data = data + "North Shore ";
data = data + "Northern Capital ";
data = data + "Northern States ";
data = data + "Northland ";
data = data + "Northwestern ";
data = data + "Northwestern Mutual Life ";
data = data + "Ohio Casualty ";
data = data + "First Security ";
data = data + "Olympia ";
data = data + "Omaha ";
data = data + "Omni ";
data = data + "Oregon Mutual ";
data = data + "Orion ";
data = data + "Oxford Insurance ";
data = data + "Pacific ";
data = data + "Pacific Life Insurance ";
data = data + "Pafco General ";
data = data + "Paloverde ";
data = data + "Pan-American Life Insurance ";
data = data + "Patriot General ";
data = data + "Peak Property and Casualty ";
data = data + "PEMCO ";
data = data + "Penn America ";
data = data + "Penn Mutual ";
data = data + "Pennsylvania Natl ";
data = data + "Phoenix ";
data = data + "Pinnacle ";
data = data + "Pioneer Life ";
data = data + "Preferred Abstainers ";
data = data + "Preferred Risk ";
data = data + "Premier ";
data = data + "Prestige ";
data = data + "Primerica ";
data = data + "Principal Financial ";
data = data + "Progressive Insurance ";
data = data + "Protective Casualty ";
data = data + "Protective Life ";
data = data + "Provident Corporation ";
data = data + "Prudential ";
data = data + "Quality ";
data = data + "RBC Liberty Insurance ";
data = data + "Ramsey ";
data = data + "Ranger ";
data = data + "Regal ";
data = data + "Reliance ";
data = data + "Reliant ";
data = data + "ReliaStar Life ";
data = data + "Republic Indemnity ";
data = data + "Response ";
data = data + "Rockford Mutual ";
data = data + "SAFECO ";
data = data + "Safeway ";
data = data + "Savings Bank Life Insurance ";
data = data + "Sea West Insurance ";
data = data + "Secura ";
data = data + "Security Co of Hartford ";
data = data + "Security National Co of FL ";
data = data + "Sedgwick James ";
data = data + "Sentinel ";
data = data + "Sentry Group ";
data = data + "Shelter Co. ";
data = data + "Skandia ";
data = data + "Spectrum ";
data = data + "St. Paul ";
data = data + "Standard Fire Company ";
data = data + "Standard Guaranty ";
data = data + "State Auto ";
data = data + "State Farm ";
data = data + "State Mutual ";
data = data + "State National Ins ";
data = data + "Sun Coast ";
data = data + "Sun Life ";
data = data + "Superior ";
data = data + "Sutter ";
data = data + "TICO ";
data = data + "TIG Countrywide ";
data = data + "Titan ";
data = data + "Total ";
data = data + "Tower ";
data = data + "Travelers ";
data = data + "Tri-State Consumer ";
data = data + "Trinity Universal ";
data = data + "Trust Hall ";
data = data + "Twentieth Century ";
data = data + "Twin City Fire ";
data = data + "UGA ";
data = data + "Unicare ";
data = data + "Uniguard ";
data = data + "Union ";
data = data + "United American ";
data = data + "United Financial ";
data = data + "United Fire & Casual ";
data = data + "United Security ";
data = data + "United States Fideli ";
data = data + "Unitrin ";
data = data + "Unsure ";
data = data + "US Health Advisors ";
data = data + "USF&G ";
data = data + "USAA ";
data = data + "Utah Home and Fire ";
data = data + "Utica ";
data = data + "Vasa North Atlantic ";
data = data + "Vigilant ";
data = data + "Viking County Mutual ";
data = data + "Viking Co of WI ";
data = data + "Wausau Insurance ";
data = data + "Wawaunesa ";
data = data + "Wellington ";
data = data + "West American ";
data = data + "West Bend Mutual ";
data = data + "West Field ";
data = data + "West Plains ";
data = data + "Western Mutal ";
data = data + "Western National ";
data = data + "Western Southern Life ";
data = data + "Westfield ";
data = data + "William Penn Life ";
data = data + "Windsor ";
data = data + "Windstar ";
data = data + "Wisconsin Mutual ";
data = data + "Workmans Auto ";
data = data + "WorldWide ";
data = data + "Yellow Key ";
data = data + "Yosemite ";
data = data + "Zurich North America ";
data = data + "Other Company (Not Listed) ";
data = data + " Do you want coverage for your spouse? * --Select-- Yes No Not Applicable Do you want coverage for your children? * --Select-- Yes No Not Applicable What type of life insurance coverage are you interested in? * ";
data = data + "";
data = data + "";
data = data + "";
data = data + "";
data = data + "--Select-- ";
data = data + "$10,000 ";
data = data + "$25,000 ";
data = data + "$50,000 ";
data = data + "$75,000 ";
data = data + "$100,000 ";
data = data + "$150,000 ";
data = data + "$200,000 ";
data = data + "$250,000 ";
data = data + "$300,000 ";
data = data + "$350,000 ";
data = data + "$400,000 ";
data = data + "$450,000 ";
data = data + "$500,000 ";
data = data + "$600,000 ";
data = data + "$700,000 ";
data = data + "$800,000 ";
data = data + "$900,000 ";
data = data + "$1 MILLION ";
data = data + "$1.5 MILLION ";
data = data + "$2 MILLION ";
data = data + "$2.5 MILLION ";
data = data + "$3 MILLION ";
data = data + "$3.5 MILLION ";
data = data + "$4 MILLION ";
data = data + "$4.5 MILLION ";
data = data + "$5 MILLION ";
data = data + "$6 MILLION ";
data = data + "$7 MILLION ";
data = data + "$8 MILLION ";
data = data + "$9 MILLION ";
data = data + "$10+ MILLION ";
data = data + "NOT SURE ";
data = data + " ";
data = data + "--Select-- ";
data = data + "Term 1 Year Annually Renewable ";
data = data + "Term 5 Year Guaranteed Level Premium ";
data = data + "Term 10 Year Guaranteed Level Premium ";
data = data + "Term 15 Year Guaranteed Level Premium ";
data = data + "Term 20 Year Guaranteed Level Premium ";
data = data + "Term 25 Year Guaranteed Level Premium ";
data = data + "Term 30 Year Guaranteed Level Premium ";
data = data + " ";
data = data + "
";
data = data + " ";
data = data + " ";
data = data + "";
data = data + "";
data = data + "";
data = data + "";
data = data + "";
data = data + "--Select-- ";
data = data + "$10,000 ";
data = data + "$25,000 ";
data = data + "$50,000 ";
data = data + "$75,000 ";
data = data + "$100,000 ";
data = data + "$150,000 ";
data = data + "$200,000 ";
data = data + "$250,000 ";
data = data + "$300,000 ";
data = data + "$350,000 ";
data = data + "$400,000 ";
data = data + "$450,000 ";
data = data + "$500,000 ";
data = data + "$600,000 ";
data = data + "$700,000 ";
data = data + "$800,000 ";
data = data + "$900,000 ";
data = data + "$1 MILLION ";
data = data + "$1.5 MILLION ";
data = data + "$2 MILLION ";
data = data + "$2.5 MILLION ";
data = data + "$3 MILLION ";
data = data + "$3.5 MILLION ";
data = data + "$4 MILLION ";
data = data + "$4.5 MILLION ";
data = data + "$5 MILLION ";
data = data + "$6 MILLION ";
data = data + "$7 MILLION ";
data = data + "$8 MILLION ";
data = data + "$9 MILLION ";
data = data + "$10+ MILLION ";
data = data + "NOT SURE ";
data = data + " ";
data = data + "--Select-- ";
data = data + "Permanent Whole ";
data = data + "Permanent Universal ";
data = data + "Permanent Variable ";
data = data + " ";
data = data + "
";
data = data + " ";
data = data + " ";
data = data + "";
data = data + "";
data = data + "";
data = data + "";
data = data + "";
data = data + "--Select-- ";
data = data + "$10,000 ";
data = data + "$25,000 ";
data = data + "$50,000 ";
data = data + "$75,000 ";
data = data + "$100,000 ";
data = data + "$150,000 ";
data = data + "$200,000 ";
data = data + "$250,000 ";
data = data + "$300,000 ";
data = data + "$350,000 ";
data = data + "$400,000 ";
data = data + "$450,000 ";
data = data + "$500,000 ";
data = data + "$600,000 ";
data = data + "$700,000 ";
data = data + "$800,000 ";
data = data + "$900,000 ";
data = data + "$1 MILLION ";
data = data + "$1.5 MILLION ";
data = data + "$2 MILLION ";
data = data + "$2.5 MILLION ";
data = data + "$3 MILLION ";
data = data + "$3.5 MILLION ";
data = data + "$4 MILLION ";
data = data + "$4.5 MILLION ";
data = data + "$5 MILLION ";
data = data + "$6 MILLION ";
data = data + "$7 MILLION ";
data = data + "$8 MILLION ";
data = data + "$9 MILLION ";
data = data + "$10+ MILLION ";
data = data + "NOT SURE ";
data = data + " ";
data = data + " ";
data = data + " ";
data = data + "
";
data = data + " ";
data = data + " ";
data = data + "Best Time to Contact You * Select Morning Afternoon evening How soon do you need this policy? * Select Immediately 48 Hours This Week
";
//end of life ins new fields
}
document.getElementById("pop").innerHTML=data;
}