document.write('<!-- phpForms.net form BEGIN -->');
document.write('<style>');
document.write('<!--');
document.write('.phpForms_pgtitle');
document.write('{');
document.write('    font-family : Arial;');
document.write('    font-size   : 18px;');
document.write('    color       : #1200d9;');
document.write('    font-weight : bold;');
document.write('}');
document.write('.phpForms_btn');
document.write('{');
document.write('    border-top-width    : 1px;');
document.write('    border-left-width   : 1px;');
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document.write('    border-right-width  : 1px;');
document.write('    border-top-color    : #e4e4e4;');
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document.write('    font-family         : Verdana, Arial, Helvetica, sans-serif;');
document.write('    color               : #000000;');
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document.write('</style>');


FPList_frm_23ee8c5840 = new Array();

   var aIds_frm_23ee8c5840 = Array( 'pg_2c35e4504f' );
   var aId_frm_23ee8c5840  = Array ();
function ChangePage_frm_23ee8c5840( to_hide, to_show )
{
   var tbl_hide = document.getElementById( aIds_frm_23ee8c5840[to_hide] );
   var tbl_show = document.getElementById( aIds_frm_23ee8c5840[to_show] );

   if ( typeof(tbl_hide)=='object' && tbl_hide!=null )
    if ( typeof(tbl_show)=='object' && tbl_show!=null )
    {
       tbl_hide.style.display = 'none';
       tbl_show.style.display = '';
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}
function NotEmpty( old_res, id, field_title )
{
   if ( old_res==0 )
   {
      var el = document.getElementById( id );
      if ( typeof(el)=='object' && el!=null )
        if ( el.value=='' )
        {
           alert( 'You should fill "' + field_title + '"' );
           return 1;
        }
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   return 0;
}
function NumbersOnly( old_res, id, field_title )
{
   if ( old_res==0 )
   {
      var el = document.getElementById( id );
      if ( typeof(el)=='object' && el!=null )
      {
         var re = /^[0-9]+$/;
         if (el.value.search(re) == -1 )
         {
            alert( '"' + field_title + '" must be a number' );
            return 1;
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   return 0;
}
function Email( old_res, id, field_title )
{ 
   if ( old_res==0 )
   {
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      if ( typeof(el)=='object' && el!=null && el.value!='' )
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         if (el.value.search(re) != -1 )  return 0;
         else
         {
            alert( '"'+field_title+'" must be email' );
            return 1;
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}






document.write('<form name=\"frm_23ee8c5840\" id=\"frm_23ee8c5840\" method=\"POST\" enctype=\"multipart/form-data\" action=\"http://activeinsurancecompany.co.uk/forms/index.php?sid=0\" onSubmit=\"return false;\">');
document.write('<input type=\"hidden\" name=\"act\" value=\"idx\">');
document.write('<input type=\"hidden\" name=\"code\" value=\"01\">');
document.write('<input type=\"hidden\" name=\"fid\" value=\"23ee8c5840\">');



function CheckPage_frm_23ee8c5840_2c35e4504f()
{
   var nResult = 0;
      nResult += NotEmpty( nResult, 'fld_62cf447340','First Name' );
   nResult += NotEmpty( nResult, 'fld_ecd00aba3c','Last Name' );
   nResult += NumbersOnly( nResult, 'fld_267e9e902c','Daytime Telephone' );
   nResult += Email( nResult, 'fld_58d3596e25','Email' );
   nResult += NotEmpty( nResult, 'fld_ee32c745ed','Postcode' );
   nResult += NotEmpty( nResult, 'fld_767686166d','Address' );

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   {  
      
      if (1)
      {
         var el = document.getElementById( 'frm_23ee8c5840' );
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		 {
			el.submit()
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      else 
        {
            ChangePage_frm_23ee8c5840( 0, 1 );
            document.location.href="#";
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}
function SetFDate(fld_id)
{
	var cur_date = new Date();
	var minutes = cur_date.getMinutes();
	var hour= cur_date.getHours();
	var day = cur_date.getDate();
	var month = cur_date.getMonth();
	var year = cur_date.getFullYear();
	var eDay = document.getElementById('fld_d_' + fld_id);
	if ( typeof(eDay )=='object' && eDay != null )
	{
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	var eMonth = document.getElementById('fld_m_' + fld_id);
	if ( typeof(eMonth)=='object' && eMonth != null )
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document.write('     <!-- Page -->');
document.write('     <table id=\"pg_2c35e4504f\" border=\"0\" cellpadding=\"2\" cellspacing=\"1\" width=\"600\" bgcolor=\"#efefef\" class=\"phpForms_main\" style=\"display:table;border: solid 1px #777777;\">');
document.write('      <tr>  <!-- Page title -->');
document.write('          <td colspan=\"2\" align=\"center\" vAlign=\"top\">');
document.write('             <span class=\"phpForms_pgtitle\">Fleet Insurance Quote</span>');
document.write('          </td>');
document.write('      </tr> <!-- /Page title -->');

document.write('      <tr>  <!-- Page top text -->');
document.write('          <td colspan=\"2\" align=\"center\">');
document.write('          ');
document.write('          </td>');
document.write('      </tr> <!-- /Page top text -->');

document.write('      <tr>');
document.write('          <td width=\"30%\" align=\"left\" bgcolor=\"#cdcdcd\" valign=\"top\">');
document.write('             <span style=\"\">Title</span>');
document.write('          </td>');
document.write('          <td width=\"70%\" align=\"left\" bgcolor=\"#cdcdcd\">');
document.write('             <select name=\"fld_7778d32743\" id=\"fld_7778d32743\" style=\"width: 80px\">');
document.write('  <option value=\'Mr\' selected>Mr</option>');
document.write('<option value=\'Mrs\'>Mrs</option>');
document.write('<option value=\'Miss\'>Miss</option>');
document.write('<option value=\'Ms\'>Ms</option>');

document.write('</select>');

document.write('          </td>');
document.write('      </tr>');
document.write('      <tr>');
document.write('          <td width=\"30%\" align=\"left\" bgcolor=\"#cdcdcd\" valign=\"top\">');
document.write('             <span style=\"\">First Name</span>&nbsp;<font color=\'red\'>*</font>');
document.write('          </td>');
document.write('          <td width=\"70%\" align=\"left\" bgcolor=\"#cdcdcd\">');
document.write('             <input type=\"text\" name=\"fld_62cf447340\"   id=\"fld_62cf447340\" value=\"\" style=\"width: 300px\">');
document.write('          </td>');
document.write('      </tr>');
document.write('      <tr>');
document.write('          <td width=\"30%\" align=\"left\" bgcolor=\"#cdcdcd\" valign=\"top\">');
document.write('             <span style=\"\">Last Name</span>&nbsp;<font color=\'red\'>*</font>');
document.write('          </td>');
document.write('          <td width=\"70%\" align=\"left\" bgcolor=\"#cdcdcd\">');
document.write('             <input type=\"text\" name=\"fld_ecd00aba3c\"   id=\"fld_ecd00aba3c\" value=\"\" style=\"width: 300px\">');
document.write('          </td>');
document.write('      </tr>');
document.write('      <tr>');
document.write('          <td width=\"30%\" align=\"left\" bgcolor=\"#cdcdcd\" valign=\"top\">');
document.write('             <span style=\"\">Daytime Telephone</span>&nbsp;<font color=\'red\'>*</font>');
document.write('          </td>');
document.write('          <td width=\"70%\" align=\"left\" bgcolor=\"#cdcdcd\">');
document.write('             <input type=\"text\" name=\"fld_267e9e902c\"   id=\"fld_267e9e902c\" value=\"\" style=\"width: 300px\">');
document.write('          </td>');
document.write('      </tr>');
document.write('      <tr>');
document.write('          <td width=\"30%\" align=\"left\" bgcolor=\"#cdcdcd\" valign=\"top\">');
document.write('             <span style=\"\">Email</span>&nbsp;<font color=\'red\'>*</font>');
document.write('          </td>');
document.write('          <td width=\"70%\" align=\"left\" bgcolor=\"#cdcdcd\">');
document.write('             <input type=\"text\" name=\"fld_58d3596e25\"   id=\"fld_58d3596e25\" value=\"\" style=\"width: 300px\">');
document.write('          </td>');
document.write('      </tr>');
document.write('      <tr>');
document.write('          <td width=\"30%\" align=\"left\" bgcolor=\"#cdcdcd\" valign=\"top\">');
document.write('             <span style=\"\">Postcode</span>&nbsp;<font color=\'red\'>*</font>');
document.write('          </td>');
document.write('          <td width=\"70%\" align=\"left\" bgcolor=\"#cdcdcd\">');
document.write('             <input type=\"text\" name=\"fld_ee32c745ed\"   id=\"fld_ee32c745ed\" value=\"\" style=\"width: 100px\">');
document.write('          </td>');
document.write('      </tr>');
document.write('      <tr>');
document.write('          <td width=\"30%\" align=\"left\" bgcolor=\"#cdcdcd\" valign=\"top\">');
document.write('             <span style=\"\">Address</span>&nbsp;<font color=\'red\'>*</font>');
document.write('          </td>');
document.write('          <td width=\"70%\" align=\"left\" bgcolor=\"#cdcdcd\">');
document.write('             <textarea name=\"fld_767686166d\" id=\"fld_767686166d\" rows=\"0\" style=\"width: 300px\"></textarea>');

document.write('          </td>');
document.write('      </tr>');
document.write('<tr><td colspan=\"2\" bgcolor=\"#cdcdcd\">');
document.write('<p></p>');
document.write('</td></tr>');
document.write('      <tr>');
document.write('          <td width=\"30%\" align=\"left\" bgcolor=\"#cdcdcd\" valign=\"top\">');
document.write('             <span style=\"\">Company Name</span>');
document.write('          </td>');
document.write('          <td width=\"70%\" align=\"left\" bgcolor=\"#cdcdcd\">');
document.write('             <input type=\"text\" name=\"fld_7da7825d99\"   id=\"fld_7da7825d99\" value=\"\" style=\"width: 300px\">');
document.write('          </td>');
document.write('      </tr>');
document.write('      <tr>');
document.write('          <td width=\"30%\" align=\"left\" bgcolor=\"#cdcdcd\" valign=\"top\">');
document.write('             <span style=\"\">Type of Business</span>&nbsp;<font color=\'red\'>*</font>');
document.write('          </td>');
document.write('          <td width=\"70%\" align=\"left\" bgcolor=\"#cdcdcd\">');
document.write('             <input type=\"text\" name=\"fld_d678c74fb5\"   id=\"fld_d678c74fb5\" value=\"\" style=\"width: 300px\">');
document.write('          </td>');
document.write('      </tr>');
document.write('      <tr>');
document.write('          <td width=\"30%\" align=\"left\" bgcolor=\"#cdcdcd\" valign=\"top\">');
document.write('             <span style=\"\">Fleet Activity Includes</span>');
document.write('          </td>');
document.write('          <td width=\"70%\" align=\"left\" bgcolor=\"#cdcdcd\">');
document.write('             <input type=\"checkbox\" name=\"fld_829beb3625[]\" id=\"614d2e9516\"   value=\"Coach\" style=\"\"><label for=\"614d2e9516\">Coach</label><br />');
document.write('<input type=\"checkbox\" name=\"fld_829beb3625[]\" id=\"4a5831f1a2\"   value=\"Courier\" style=\"\"><label for=\"4a5831f1a2\">Courier</label><br />');
document.write('<input type=\"checkbox\" name=\"fld_829beb3625[]\" id=\"675ee58314\"   value=\"Haulage\" style=\"\"><label for=\"675ee58314\">Haulage</label><br />');
document.write('<input type=\"checkbox\" name=\"fld_829beb3625[]\" id=\"f3084e4049\"   value=\"Other Commercial\" style=\"\"><label for=\"f3084e4049\">Other Commercial</label><br />');
document.write('<input type=\"checkbox\" name=\"fld_829beb3625[]\" id=\"da06e93725\"   value=\"Taxi / Private Hire\" style=\"\"><label for=\"da06e93725\">Taxi / Private Hire</label>');
document.write('          </td>');
document.write('      </tr>');
document.write('      <tr>');
document.write('          <td width=\"30%\" align=\"left\" bgcolor=\"#cdcdcd\" valign=\"top\">');
document.write('             <span style=\"\">Number of Vehicles</span>');
document.write('          </td>');
document.write('          <td width=\"70%\" align=\"left\" bgcolor=\"#cdcdcd\">');
document.write('             <select name=\"fld_e4225ae7bb\" id=\"fld_e4225ae7bb\" style=\"width: 120px\">');
document.write('  <option value=\'Please Select..\'>Please Select..</option>');
document.write('<option value=\'1\'>1</option>');
document.write('<option value=\'2\'>2</option>');
document.write('<option value=\'3\'>3</option>');
document.write('<option value=\'4\'>4</option>');
document.write('<option value=\'5\'>5</option>');
document.write('<option value=\'6\'>6</option>');
document.write('<option value=\'7\'>7</option>');
document.write('<option value=\'8\'>8</option>');
document.write('<option value=\'9\'>9</option>');
document.write('<option value=\'10\'>10</option>');
document.write('<option value=\'11\'>11</option>');
document.write('<option value=\'12\'>12</option>');
document.write('<option value=\'13\'>13</option>');
document.write('<option value=\'14\'>14</option>');
document.write('<option value=\'15\'>15</option>');
document.write('<option value=\'16\'>16</option>');
document.write('<option value=\'17\'>17</option>');
document.write('<option value=\'18\'>18</option>');
document.write('<option value=\'19\'>19</option>');
document.write('<option value=\'20+\'>20+</option>');

document.write('</select>');

document.write('          </td>');
document.write('      </tr>');
document.write('<tr><td colspan=\"2\" bgcolor=\"#cdcdcd\">');
document.write('<p></p>');
document.write('</td></tr>');
document.write('      <tr>');
document.write('          <td width=\"30%\" align=\"left\" bgcolor=\"#cdcdcd\" valign=\"top\">');
document.write('             <span style=\"\">Do you have an existing policy that is due for renewal?</span>&nbsp;<font color=\'red\'>*</font>');
document.write('          </td>');
document.write('          <td width=\"70%\" align=\"left\" bgcolor=\"#cdcdcd\">');
document.write('             <input type=\"radio\" name=\"fld_f91aa7b8eb\" id=\"376c6b0db0\"   value=\"Yes\" style=\"\"><label for=\"376c6b0db0\">Yes</label><br />');
document.write('<input type=\"radio\" name=\"fld_f91aa7b8eb\" id=\"d3eac9a85b\"   value=\"No\" style=\"\"><label for=\"d3eac9a85b\">No</label>');
document.write('          </td>');
document.write('      </tr>');
document.write('      <tr>');
document.write('          <td width=\"30%\" align=\"left\" bgcolor=\"#cdcdcd\" valign=\"top\">');
document.write('             <span style=\"\">Policy Required From?</span>&nbsp;<font color=\'red\'>*</font>');
document.write('          </td>');
document.write('          <td width=\"70%\" align=\"left\" bgcolor=\"#cdcdcd\">');
document.write('             <select onChange=\"\" name=\"fld_d_68ac008fea\" id=\"fld_d_68ac008fea\" style=\"\">');
document.write(' <option value=\'1\'>1</option>');
document.write('<option value=\'2\'>2</option>');
document.write('<option value=\'3\'>3</option>');
document.write('<option value=\'4\'>4</option>');
document.write('<option value=\'5\'>5</option>');
document.write('<option value=\'6\'>6</option>');
document.write('<option value=\'7\'>7</option>');
document.write('<option value=\'8\' selected>8</option>');
document.write('<option value=\'9\'>9</option>');
document.write('<option value=\'10\'>10</option>');
document.write('<option value=\'11\'>11</option>');
document.write('<option value=\'12\'>12</option>');
document.write('<option value=\'13\'>13</option>');
document.write('<option value=\'14\'>14</option>');
document.write('<option value=\'15\'>15</option>');
document.write('<option value=\'16\'>16</option>');
document.write('<option value=\'17\'>17</option>');
document.write('<option value=\'18\'>18</option>');
document.write('<option value=\'19\'>19</option>');
document.write('<option value=\'20\'>20</option>');
document.write('<option value=\'21\'>21</option>');
document.write('<option value=\'22\'>22</option>');
document.write('<option value=\'23\'>23</option>');
document.write('<option value=\'24\'>24</option>');
document.write('<option value=\'25\'>25</option>');
document.write('<option value=\'26\'>26</option>');
document.write('<option value=\'27\'>27</option>');
document.write('<option value=\'28\'>28</option>');
document.write('<option value=\'29\'>29</option>');
document.write('<option value=\'30\'>30</option>');

document.write('</select>');
document.write('&nbsp;');
document.write('<select onChange=\"\" name=\"fld_m_68ac008fea\" id=\"fld_m_68ac008fea\" style=\"\">');
document.write(' <option value=\'Jan\'>Jan</option>');
document.write('<option value=\'Feb\'>Feb</option>');
document.write('<option value=\'Mar\'>Mar</option>');
document.write('<option value=\'Apr\'>Apr</option>');
document.write('<option value=\'May\'>May</option>');
document.write('<option value=\'Jun\'>Jun</option>');
document.write('<option value=\'Jul\'>Jul</option>');
document.write('<option value=\'Aug\'>Aug</option>');
document.write('<option value=\'Sep\' selected>Sep</option>');
document.write('<option value=\'Oct\'>Oct</option>');
document.write('<option value=\'Nov\'>Nov</option>');
document.write('<option value=\'Dec\'>Dec</option>');

document.write('</select>');
document.write('&nbsp;');
document.write('<select onChange=\"\" name=\"fld_y_68ac008fea\" id=\"fld_y_68ac008fea\" style=\"\">');
document.write(' <option value=\'2010\' selected>2010</option>');

document.write('</select>');
document.write('&nbsp;');



function Sel_currd()
{ 
   currd = new Date();
   var sel_Year = document.getElementById("fld_y_68ac008fea");
   var sel_Month = document.getElementById("fld_m_68ac008fea");
   var sel_Day  = document.getElementById("fld_d_68ac008fea");

   for (i=0; i<sel_Year.length; i++)
   {
      if ( sel_Year[i].value == currd.getYear() + 1900 )
      {
        sel_Year.options[i].selected = true;
		break;
      }
   }

   if ( typeof(sel_Month)=='object' && sel_Month!=null )
   sel_Month.options[currd.getMonth()].selected = true;

   if ( typeof(sel_Day)=='object' && sel_Day!=null )
   sel_Day.options[currd.getDate()-1].selected = true;
}

 Sel_currd();

document.write(' ');

			SetFDate('68ac008fea');
document.write('			');
document.write('          </td>');
document.write('      </tr>');
document.write('      <tr>');
document.write('          <td width=\"30%\" align=\"left\" bgcolor=\"#cdcdcd\" valign=\"top\">');
document.write('             <span style=\"\">Upload Vehicle Schedule</span>');
document.write('          </td>');
document.write('          <td width=\"70%\" align=\"left\" bgcolor=\"#cdcdcd\">');
document.write('             <input type=\"file\" name=\"fld_9e2579cf4f\" id=\"fld_9e2579cf4f\" style=\"width: 300px\">');
document.write('          </td>');
document.write('      </tr>');
document.write('      <tr>');
document.write('          <td width=\"30%\" align=\"left\" bgcolor=\"#cdcdcd\" valign=\"top\">');
document.write('             <span style=\"\">Upload Claims Experience</span>');
document.write('          </td>');
document.write('          <td width=\"70%\" align=\"left\" bgcolor=\"#cdcdcd\">');
document.write('             <input type=\"file\" name=\"fld_89cfd68a10\" id=\"fld_89cfd68a10\" style=\"width: 300px\">');
document.write('          </td>');
document.write('      </tr>');
document.write('      <tr>');
document.write('          <td width=\"30%\" align=\"left\" bgcolor=\"#cdcdcd\" valign=\"top\">');
document.write('             <span style=\"\">Name of Existing Insurer</span>');
document.write('          </td>');
document.write('          <td width=\"70%\" align=\"left\" bgcolor=\"#cdcdcd\">');
document.write('             <input type=\"text\" name=\"fld_29fb1fdf1b\"   id=\"fld_29fb1fdf1b\" value=\"\" style=\"width: 300px\">');
document.write('          </td>');
document.write('      </tr>');
document.write('      <tr>');
document.write('          <td width=\"30%\" align=\"left\" bgcolor=\"#cdcdcd\" valign=\"top\">');
document.write('             <span style=\"\">Renewal Premium?</span>');
document.write('          </td>');
document.write('          <td width=\"70%\" align=\"left\" bgcolor=\"#cdcdcd\">');
document.write('             <input type=\"text\" name=\"fld_ccd5046387\"   id=\"fld_ccd5046387\" value=\"\" style=\"width: 300px\">');
document.write('          </td>');
document.write('      </tr>');


document.write('<tr>');
document.write('          <td colspan=\"2\" align=\"center\" class=\"phpForms_main\">');
document.write('            ');
document.write('          </td>');
document.write('      </tr>');
document.write('<tr>');
document.write('          <td colspan=\"2\" align=\"center\" class=\"phpForms_main\">');

document.write('          </td>');
document.write('      </tr>');
document.write('      <tr>');
document.write('          <!-- Buttons -->');
document.write('          <td colspan=\"2\" align=\"center\" class=\"phpForms_main\">');
document.write('<input type=\"button\" id=\"subbut_23ee8c5840\" value=\"Submit\" onClick=\'CheckPage_frm_23ee8c5840_2c35e4504f(0);\' style=\"width:30%; background-color : #a2a2a2\" class=\"phpForms_btn\">');

document.write('          </td>');
document.write('      </tr>');
document.write('      <tr>  <!-- Page bottom text -->');
document.write('          <td colspan=\"2\" align=\"center\">');
document.write('          <hr>');
document.write('              ');
document.write('          </td>');
document.write('      </tr> <!-- /Page bottom text -->');

document.write('     </table>');
document.write('     <!-- /Page -->');


document.write('</form>');


document.write('<!-- /phpForms.net form END -->');