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;');
document.write('    border-bottom-width : 1px;');
document.write('    border-right-width  : 1px;');
document.write('    border-top-color    : #e4e4e4;');
document.write('    border-left-color   : #e4e4e4;');
document.write('    border-right-color  : #c1c1c1;');
document.write('    border-bottom-color : #c1c1c1;');
document.write('    font-family         : Verdana, Arial, Helvetica, sans-serif;');
document.write('    color               : #000000;');
document.write('}');
document.write('-->');
document.write('</style>');


FPList_frm_c572b10cbc = new Array();

   var aIds_frm_c572b10cbc = Array( 'pg_e3c51f1dc7' );
   var aId_frm_c572b10cbc  = Array ();
function ChangePage_frm_c572b10cbc( to_hide, to_show )
{
   var tbl_hide = document.getElementById( aIds_frm_c572b10cbc[to_hide] );
   var tbl_show = document.getElementById( aIds_frm_c572b10cbc[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 = '';
    }
	
}
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;
        }
   }
   return 0;
}
function Email( old_res, id, field_title )
{ 
   if ( old_res==0 )
   {
      var el = document.getElementById( id );
      if ( typeof(el)=='object' && el!=null && el.value!='' )
      {
         var re = /^[a-zA-Z0-9_\.\-]+@([a-zA-Z0-9][a-zA-Z0-9-]+\.)+[a-zA-Z]{2,6}$/;

         if (el.value.search(re) != -1 )  return 0;
         else
         {
            alert( '"'+field_title+'" must be email' );
            return 1;
         }
      }
   }
   return 0;
}






document.write('<form name=\"frm_c572b10cbc\" id=\"frm_c572b10cbc\" 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=\"c572b10cbc\">');



function CheckPage_frm_c572b10cbc_e3c51f1dc7()
{
   var nResult = 0;
      nResult += NotEmpty( nResult, 'fld_f5c2572c2e','Full Name' );
   nResult += NotEmpty( nResult, 'fld_9d5eea42e2','Address' );
   nResult += NotEmpty( nResult, 'fld_904f5c5526','Postcode' );
   nResult += NotEmpty( nResult, 'fld_12c76a2c65','Telephone' );
   nResult += Email( nResult, 'fld_a67793783f','Email' );
   nResult += NotEmpty( nResult, 'fld_159364439b','Details' );

   if ( nResult == 0 )
   {  
      
      if (1)
      {
         var el = document.getElementById( 'frm_c572b10cbc' );
         if ( typeof(el)=='object' && el != null )
		 {
			el.submit()
		}
      }
      else 
        {
            ChangePage_frm_c572b10cbc( 0, 1 );
            document.location.href="#";
        }
   } 
}
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 )
	{
		eDay.options[day].selected = 'selected';
	}
	var eHour= document.getElementById('fld_h_' + fld_id);
	if ( typeof(eHour)=='object' && eHour != null )
	{
		eHour.options[hour].selected = 'selected';
	}
	var eMinutes = document.getElementById('fld_i_' + fld_id);
	if ( typeof(eMinutes)=='object' && eMinutes != null )
	{
		eMinutes.options[minutes].selected = 'selected';
	}
	var eMonth = document.getElementById('fld_m_' + fld_id);
	if ( typeof(eMonth)=='object' && eMonth != null )
	{
		eMonth.options[month].selected = 'selected';
	}
	var eYear = document.getElementById('fld_y_' + fld_id);
	if ( typeof(eYear)=='object' && eYear != null )
	{
		for(i=0;i<eYear.length; i++)
		{
			if (eYear.options[i].value == year)
			{
				eYear.options[i].selected = 'selected';
			}
		}
	}
}



document.write('     <!-- Page -->');
document.write('     <table id=\"pg_e3c51f1dc7\" border=\"0\" cellpadding=\"2\" cellspacing=\"1\" width=\"450\" bgcolor=\"#EE5C42\" 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\"></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=\"#EE5C42\" valign=\"top\">');
document.write('             <span style=\"\">Full Name</span>&nbsp;<font color=\'red\'>*</font>');
document.write('          </td>');
document.write('          <td width=\"70%\" align=\"left\" bgcolor=\"#EE5C42\">');
document.write('             <input type=\"text\" name=\"fld_f5c2572c2e\"   id=\"fld_f5c2572c2e\" value=\"\" style=\"width:100%;\">');
document.write('          </td>');
document.write('      </tr>');
document.write('      <tr>');
document.write('          <td width=\"30%\" align=\"left\" bgcolor=\"#EE5C42\" valign=\"top\">');
document.write('             <span style=\"\">Address</span>&nbsp;<font color=\'red\'>*</font>');
document.write('          </td>');
document.write('          <td width=\"70%\" align=\"left\" bgcolor=\"#EE5C42\">');
document.write('             <textarea name=\"fld_9d5eea42e2\" id=\"fld_9d5eea42e2\" rows=\"5\" style=\"width:100%;\"></textarea>');

document.write('          </td>');
document.write('      </tr>');
document.write('      <tr>');
document.write('          <td width=\"30%\" align=\"left\" bgcolor=\"#EE5C42\" valign=\"top\">');
document.write('             <span style=\"\">Postcode</span>&nbsp;<font color=\'red\'>*</font>');
document.write('          </td>');
document.write('          <td width=\"70%\" align=\"left\" bgcolor=\"#EE5C42\">');
document.write('             <input type=\"text\" name=\"fld_904f5c5526\"   id=\"fld_904f5c5526\" value=\"\" style=\"width:100%;\">');
document.write('          </td>');
document.write('      </tr>');
document.write('      <tr>');
document.write('          <td width=\"30%\" align=\"left\" bgcolor=\"#EE5C42\" valign=\"top\">');
document.write('             <span style=\"\">Mobile</span>');
document.write('          </td>');
document.write('          <td width=\"70%\" align=\"left\" bgcolor=\"#EE5C42\">');
document.write('             <input type=\"text\" name=\"fld_47be50943c\"   id=\"fld_47be50943c\" value=\"\" style=\"width:100%;\">');
document.write('          </td>');
document.write('      </tr>');
document.write('      <tr>');
document.write('          <td width=\"30%\" align=\"left\" bgcolor=\"#EE5C42\" valign=\"top\">');
document.write('             <span style=\"\">Telephone</span>&nbsp;<font color=\'red\'>*</font>');
document.write('          </td>');
document.write('          <td width=\"70%\" align=\"left\" bgcolor=\"#EE5C42\">');
document.write('             <input type=\"text\" name=\"fld_12c76a2c65\"   id=\"fld_12c76a2c65\" value=\"\" style=\"width:100%;\">');
document.write('          </td>');
document.write('      </tr>');
document.write('      <tr>');
document.write('          <td width=\"30%\" align=\"left\" bgcolor=\"#EE5C42\" valign=\"top\">');
document.write('             <span style=\"\">Email</span>&nbsp;<font color=\'red\'>*</font>');
document.write('          </td>');
document.write('          <td width=\"70%\" align=\"left\" bgcolor=\"#EE5C42\">');
document.write('             <input type=\"text\" name=\"fld_a67793783f\"   id=\"fld_a67793783f\" value=\"\" style=\"width:100%;\">');
document.write('          </td>');
document.write('      </tr>');
document.write('      <tr>');
document.write('          <td width=\"30%\" align=\"left\" bgcolor=\"#EE5C42\" valign=\"top\">');
document.write('             <span style=\"\">Area&#39;s of Interest</span>&nbsp;<font color=\'red\'>*</font>');
document.write('          </td>');
document.write('          <td width=\"70%\" align=\"left\" bgcolor=\"#EE5C42\">');
document.write('             <input type=\"checkbox\" name=\"fld_462a56e07e[]\" id=\"46fe3d7e99\"   value=\"Commercial Insurance\" style=\"\"><label for=\"46fe3d7e99\">Commercial Insurance</label><br />');
document.write('<input type=\"checkbox\" name=\"fld_462a56e07e[]\" id=\"338af8088b\"   value=\"Property Insurance\" style=\"\"><label for=\"338af8088b\">Property Insurance</label><br />');
document.write('<input type=\"checkbox\" name=\"fld_462a56e07e[]\" id=\"18f09fe6b5\"   value=\"Motor Fleet Insurance\" style=\"\"><label for=\"18f09fe6b5\">Motor Fleet Insurance</label><br />');
document.write('<input type=\"checkbox\" name=\"fld_462a56e07e[]\" id=\"a1a8b77885\"   value=\"Other\" style=\"\"><label for=\"a1a8b77885\">Other</label>');
document.write('          </td>');
document.write('      </tr>');
document.write('      <tr>');
document.write('          <td width=\"30%\" align=\"left\" bgcolor=\"#EE5C42\" valign=\"top\">');
document.write('             <span style=\"\">Details</span>&nbsp;<font color=\'red\'>*</font>');
document.write('          </td>');
document.write('          <td width=\"70%\" align=\"left\" bgcolor=\"#EE5C42\">');
document.write('             <textarea name=\"fld_159364439b\" id=\"fld_159364439b\" rows=\"5\" style=\"width:100%;\"></textarea>');

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_c572b10cbc\" value=\"Submit\" onClick=\'CheckPage_frm_c572b10cbc_e3c51f1dc7(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 -->');