document.write("<div id='container'>");
document.write("<div class='hpo_header_text' id='header'>Medicare Quotes</div>");
document.write("<div style='display:block;color: #666; font-weight: normal; font-size: 12px; font-family: Myriad Pro;text-align:right; margin-right:30px;'>");
document.write("<label>&nbsp;Zip:&nbsp;");
document.write("<input name='txtZip' type='text' id='txtZip' size='6' maxlength='5' style='text-align:center;padding-bottom: 1px;'/></label>");
document.write("</div>");        
document.write("<div style='display:block;color: #666; font-weight: normal; font-size: 12px; font-family: Myriad Pro; padding-top:1px; padding-bottom:1px;text-align:right; margin-right:30px;'>");     
document.write("<label>&nbsp;Age:&nbsp;");
document.write("<input name='txtAge' type='text' id='txtAge' size='6' maxlength='3' style='text-align:center;'/></label>");
document.write("</div>");     
document.write("<div style='display:block;color: #666; font-weight: normal; font-size: 12px; font-family: Myriad Pro;'>");
document.write("<input type='radio' name='txtGender' value='M'  checked='checked'/><span>Male </span>");
document.write("<input type='radio' name='txtGender' value='F' /><span>Female </span>");
document.write("</div>");
document.write("<div class='hpo_button' id='hpo_button' onclick='getQuotes();'>"); 
document.write("<b class='rtop'><b class='r1'></b><b class='r2'></b><b class='r3'></b><b class='r4'></b></b>Get Quotes<b class='rbottom'><b class='r4'></b><b class='r3'>");
document.write("</b><b class='r2'></b><b class='r1'></b></b>");
document.write("</div>");  
document.write("<div style='width: 127px; border-top-width: 1px; border-top-style: solid; border-top-color: #ccc; margin-right: 4px; margin-left: 4px; text-align: center;   color: #CCC; padding-top:3px; padding-bottom:3px;'>");
document.write("<span style='font-size: 8px; font-family: Myriad Pro; color: #666;'>Powered by HealthPlanOne</span>");
document.write("</div>");  	
document.write("<div style='clear: both;'></div>");
document.write("</div>");