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<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.1//EN" "http://www.w3.org/TR/xhtml11/DTD/xhtml11.dtd">
<html xmlns='http://www.w3.org/1999/xhtml'>
   <head >
      <meta http-equiv='Content-Type' content='text/html; charset=utf-8'/>
      <title >Form Page: Anfrage_internationale_KV_en_schnell_ASEAN</title>
      <meta name='generator' content='Simfatic Forms 4.0.12.416'/>
      <script src='scripts/jquery-1.7.2.min.js' type='text/javascript'></script>
      <script src='scripts/jquery-ui-1.8.18.custom.min.js' type='text/javascript'></script>
      <script src='scripts/jquery.sim.utils.js' type='text/javascript'></script>
      <script src='scripts/globalize.js' type='text/javascript'></script>
      <script src='scripts/globalize.culture.en-CA.js' type='text/javascript'></script>
      <script src='scripts/jquery-ui-1.8.21.custom.date.min.js' type='text/javascript'></script>
      <script src='scripts/moment.js' type='text/javascript'></script>
      <script src='scripts/sfm_calendar.js' type='text/javascript'></script>
      <script src='scripts/sfm-png-fix.js' type='text/javascript'></script>
      <script src='scripts/sfm_validatorv7.js' type='text/javascript'></script>
      <script src='scripts/jquery.sim.FormCalc.js' type='text/javascript'></script>
      <link rel='stylesheet' type='text/css' href='style/jquery-ui-1.8.16.css'/>
      <link rel='stylesheet' type='text/css' href='style/Anfrage_internationale_KV_en_schnell_ASEAN.css?r=624155613'/>
   </head>
   <body id='sfm_Anfrage_internationale_KV_en_schnell_ASEAN_body'>
      <form id='Anfrage_internationale_KV_en_schnell_ASEAN' class='sfm_form' method='post' action='/req/aseanen/Anfrage_internationale_KV_en_schnell_ASEAN.php?sfm_sid=171' accept-charset='UTF-8'>
         <div id='Anfrage_internationale_KV_en_schnell_ASEAN_errorloc' class='error_strings' style='width:375px;text-align:left'></div>
         <div id='Anfrage_internationale_KV_en_schnell_ASEAN_outer_div' class='form_outer_div' style='width:375px;height:656px'>
            <div style='position:relative' id='Anfrage_internationale_KV_en_schnell_ASEAN_inner_div'>
               <input type='hidden' name='sfm_form_submitted' value='yes'/>
               <input type='hidden' name='id_6823ac7e78fdfa362632' value='d959b1f2377b88b5d9e6596b7'/>
               <input type='text' name='t3a126b4ac69b1246730b' id='t3a126b4ac69b1246730b'/>
               <div id='heading4_container' class='form_subheading'>
                  <h2 id='heading4' class='form_subheading'>Your situation:</h2>
               </div>
               <div id='label8_container'>
                  <div id='label8'>Desired start date of coverage</div>
               </div>
               <div id='heading_container' class='form_subheading'>
                  <h2 id='heading' class='form_subheading'>Desired benefits:</h2>
               </div>
               <div id='heading2_container' class='form_subheading'>
                  <h2 id='heading2' class='form_subheading'>You:</h2>
               </div>
               <div id='label11_container'>
                  <div id='label11'>Date of birth</div>
               </div>
               <div id='heading5_container' class='form_subheading'>
                  <h2 id='heading5' class='form_subheading'>Partner / Child</h2>
               </div>
               <div id='label9_container'>
                  <div id='label9'>Date of birth</div>
               </div>
               <div id='heading3_container' class='form_subheading'>
                  <h2 id='heading3' class='form_subheading'>Your contact details</h2>
               </div>
               <div class='element_label' id='Data_Protection_container'><input type='checkbox' name='Data_Protection' id='Data_Protection' value='on' /><label for='Data_Protection' class='element_label' id='Data_Protection_label'>I hererby accept the data protection rules - http://asean-health-insurance.de/imprint.htm</label></div>
               <div id='Country_container'>
                  <input type='text' name='Country' id='Country' value='Future country of residence' size='20' tabindex='1' class='sfm_textbox'/>
               </div>
               <div id='Other_container'>
                  <input type='text' name='Other' id='Other' value='Other contries' size='20' tabindex='2' class='sfm_textbox'/>
               </div>
               <div id='Duration_container'>
                  <select name='Duration' id='Duration' size='1' tabindex='3'>
                     <option value='Duration...' >Duration...</option>
                     <option value='more than 1 year' >more than 1 year</option>
                     <option value='indefinate' >indefinate</option>
                     <option value='not sure yet' >not sure yet</option>
                  </select>
               </div>
               <div class='sfm_element_container' id='Satrt_container'>
                  <input type='text' name='Satrt' id='Satrt' tabindex='4' value=''/>
                  <input type='text' name='sfm_Satrt_parsed' id='sfm_Satrt_parsed' tabindex='-1' style='display:none'/>
                  <div id='Satrt_image_container'>
                     <img id='Satrt_image' class='sfm_datepicker_icon' src='images/calendar16x16_1.png' width='16' height='16' alt='Click here to open the date picker'/>
                  </div>
               </div>
               <div id='outpatient_container'>
                  <select name='outpatient' id='outpatient' size='1' tabindex='5'>
                     <option value='Outpatient coverage...' >Outpatient coverage...</option>
                     <option value='high' >high</option>
                     <option value='medium' >medium</option>
                     <option value='basic' >basic</option>
                     <option value='no' >no</option>
                  </select>
               </div>
               <div id='Inpatient_container'>
                  <select name='Inpatient' id='Inpatient' size='1' tabindex='6'>
                     <option value='Inpatient coverage...' >Inpatient coverage...</option>
                     <option value='Private room' >Private room</option>
                     <option value='Semi-Private room' >Semi-Private room</option>
                     <option value='either' >either</option>
                  </select>
               </div>
               <div id='Dental_container'>
                  <select name='Dental' id='Dental' size='1' tabindex='7'>
                     <option value='Dental coverage...' >Dental coverage...</option>
                     <option value='high' >high</option>
                     <option value='medium' >medium</option>
                     <option value='basic' >basic</option>
                     <option value='no' >no</option>
                  </select>
               </div>
               <div id='Checkups_container'>
                  <select name='Checkups' id='Checkups' size='1' tabindex='8'>
                     <option value='Check-ups...' >Check-ups...</option>
                     <option value='yes' >yes</option>
                     <option value='no' >no</option>
                  </select>
               </div>
               <div id='Maternity_container'>
                  <select name='Maternity' id='Maternity' size='1' tabindex='9'>
                     <option value='Maternity coverage...' >Maternity coverage...</option>
                     <option value='yes' >yes</option>
                     <option value='no' >no</option>
                  </select>
               </div>
               <div id='Deductible_container'>
                  <select name='Deductible' id='Deductible' size='1' tabindex='10'>
                     <option value='Annual deductible...' >Annual deductible...</option>
                     <option value='no' >none</option>
                     <option value='250' >yes, up to $250</option>
                     <option value='500' >yes, up to $500</option>
                     <option value='1000' >yes, up to $1,000</option>
                     <option value='2500' >yes, up to $2,500</option>
                     <option value='5000' >yes, up to $5,000</option>
                     <option value='as high as possible' >yes, as high as possible</option>
                  </select>
               </div>
               <div id='FirstNameVP1_container'>
                  <input type='text' name='FirstNameVP1' id='FirstNameVP1' value='First name' size='20' tabindex='11' class='sfm_textbox'/>
               </div>
               <div id='LastNameVP1_container'>
                  <input type='text' name='LastNameVP1' id='LastNameVP1' value='Last name' size='20' tabindex='12' class='sfm_textbox'/>
               </div>
               <div id='GenderVP1_container'>
                  <select name='GenderVP1' id='GenderVP1' size='1' tabindex='13'>
                     <option value='Gender...' >Gender...</option>
                     <option value='female' >female</option>
                     <option value='male' >male</option>
                  </select>
               </div>
               <div id='CitizenshipVP1_container'>
                  <input type='text' name='CitizenshipVP1' id='CitizenshipVP1' value='Citizenship(s)' size='20' tabindex='14' class='sfm_textbox'/>
               </div>
               <div class='sfm_element_container' id='DoBVP1_container'>
                  <input type='text' name='DoBVP1' id='DoBVP1' tabindex='15' value=''/>
                  <input type='text' name='sfm_DoBVP1_parsed' id='sfm_DoBVP1_parsed' tabindex='-1' style='display:none'/>
                  <div id='DoBVP1_image_container'>
                     <img id='DoBVP1_image' class='sfm_datepicker_icon' src='images/calendar16x16_1.png' width='16' height='16' alt='Click here to open the date picker'/>
                  </div>
               </div>
               <div id='FirstNameVP2_container'>
                  <input type='text' name='FirstNameVP2' id='FirstNameVP2' value='First name' size='20' tabindex='16' class='sfm_textbox'/>
               </div>
               <div id='LastNameVP2_container'>
                  <input type='text' name='LastNameVP2' id='LastNameVP2' value='Last name' size='20' tabindex='17' class='sfm_textbox'/>
               </div>
               <div id='GendertVP2_container'>
                  <select name='GendertVP2' id='GendertVP2' size='1' tabindex='18'>
                     <option value='Gender...' >Gender...</option>
                     <option value='female' >female</option>
                     <option value='male' >male</option>
                  </select>
               </div>
               <div id='CitizenshipVP2_container'>
                  <input type='text' name='CitizenshipVP2' id='CitizenshipVP2' value='Citizenship(s)' size='20' tabindex='19' class='sfm_textbox'/>
               </div>
               <div class='sfm_element_container' id='DoBVP2_container'>
                  <input type='text' name='DoBVP2' id='DoBVP2' tabindex='20' value=''/>
                  <input type='text' name='sfm_DoBVP2_parsed' id='sfm_DoBVP2_parsed' tabindex='-1' style='display:none'/>
                  <div id='DoBVP2_image_container'>
                     <img id='DoBVP2_image' class='sfm_datepicker_icon' src='images/calendar16x16_1.png' width='16' height='16' alt='Click here to open the date picker'/>
                  </div>
               </div>
               <div id='Title_container'>
                  <select name='Title' id='Title' size='1' tabindex='21'>
                     <option value='Title...' >Title...</option>
                     <option value='Ms.' >Ms.</option>
                     <option value='Mr.' >Mr.</option>
                  </select>
               </div>
               <div id='FirstName_container'>
                  <input type='text' name='FirstName' id='FirstName' value='First name' size='20' tabindex='22' class='sfm_textbox'/>
               </div>
               <div id='LastName_container'>
                  <input type='text' name='LastName' id='LastName' value='Last name' size='20' tabindex='23' class='sfm_textbox'/>
               </div>
               <div id='Email_container'>
                  <input type='text' name='Email' id='Email' value='E-Mail' size='20' tabindex='24' class='sfm_textbox'/>
               </div>
               <div id='EmailRepeat_container'>
                  <input type='text' name='EmailRepeat' id='EmailRepeat' value='E-Mail (please repeat)' size='20' tabindex='25' class='sfm_textbox'/>
               </div>
               <div id='Comments_container'><textarea name='Comments' id='Comments' tabindex='26' class='sfm_textarea'>Comments / More persons to be insured</textarea></div>
               <div id='Submit_container' class='loading_div'>
                  <input type='image' name='Submit' tabindex='27' id='Anfrage_internationale_KV_en_schnell_ASEAN_Submit_img' src='images/Anfrage_internationale_KV-Submit-0-0-4-2.png' alt='submit'/>
               </div>
            </div>
         </div>
      </form>
      <script type='text/javascript'>
// <![CDATA[
$(function()
{
   sfm_init_default_text("Anfrage_internationale_KV_en_schnell_ASEAN","Country","Future country of residence");
   sfm_init_default_text("Anfrage_internationale_KV_en_schnell_ASEAN","Other","Other contries");
   new sfm_calendar({input_id:"Satrt",image_id:"Satrt_image",form_id:"Anfrage_internationale_KV_en_schnell_ASEAN",mirror:"sfm_Satrt_parsed"})
   sfm_init_default_text("Anfrage_internationale_KV_en_schnell_ASEAN","FirstNameVP1","First name");
   sfm_init_default_text("Anfrage_internationale_KV_en_schnell_ASEAN","LastNameVP1","Last name");
   sfm_init_default_text("Anfrage_internationale_KV_en_schnell_ASEAN","CitizenshipVP1","Citizenship(s)");
   new sfm_calendar({input_id:"DoBVP1",image_id:"DoBVP1_image",form_id:"Anfrage_internationale_KV_en_schnell_ASEAN",mirror:"sfm_DoBVP1_parsed",yearRange:"1900:2020"})
   sfm_init_default_text("Anfrage_internationale_KV_en_schnell_ASEAN","FirstNameVP2","First name");
   sfm_init_default_text("Anfrage_internationale_KV_en_schnell_ASEAN","LastNameVP2","Last name");
   sfm_init_default_text("Anfrage_internationale_KV_en_schnell_ASEAN","CitizenshipVP2","Citizenship(s)");
   new sfm_calendar({input_id:"DoBVP2",image_id:"DoBVP2_image",form_id:"Anfrage_internationale_KV_en_schnell_ASEAN",mirror:"sfm_DoBVP2_parsed",yearRange:"1900:2020"})
   sfm_init_default_text("Anfrage_internationale_KV_en_schnell_ASEAN","FirstName","First name");
   sfm_init_default_text("Anfrage_internationale_KV_en_schnell_ASEAN","LastName","Last name");
   sfm_init_default_text("Anfrage_internationale_KV_en_schnell_ASEAN","Email","E-Mail");
   sfm_init_default_text("Anfrage_internationale_KV_en_schnell_ASEAN","EmailRepeat","E-Mail (please repeat)");
   sfm_show_loading_on_formsubmit('Anfrage_internationale_KV_en_schnell_ASEAN','Anfrage_internationale_KV_en_schnell_ASEAN_Submit_img');
});
Globalize.culture('en-CA')
sfm_fix_png("Anfrage_internationale_KV_en_schnell_ASEAN_Submit_img","images/spacer.gif");

// ]]>
      </script>
      <script type='text/javascript'>
// <![CDATA[
var Anfrage_internationale_KV_en_schnell_ASEANValidator = new Validator("Anfrage_internationale_KV_en_schnell_ASEAN",{enable_smart_live_validation:false, message_style:'messagebox', error_popup:{message_pos:'top'}});
Anfrage_internationale_KV_en_schnell_ASEANValidator.addValidation("Data_Protection",{selmin:"1",message:"Please confirm that you accept our data protection rules."} );
Anfrage_internationale_KV_en_schnell_ASEANValidator.addValidation("Country",{required:true,message:"Please fill in your main country of residence."} );
Anfrage_internationale_KV_en_schnell_ASEANValidator.addValidation("Duration",{dontselect:"Duration...",message:"How long do you need coverage for?"} );
Anfrage_internationale_KV_en_schnell_ASEANValidator.addValidation("Satrt",{required:true,message:"When shall the coverage start?"} );
Anfrage_internationale_KV_en_schnell_ASEANValidator.addValidation("Satrt",{after_date:"SameDay",message:"Start date has to be in the future."} );
Anfrage_internationale_KV_en_schnell_ASEANValidator.addValidation("outpatient",{dontselect:"Outpatient coverage...",message:"Please select an option for outpatient coverage"} );
Anfrage_internationale_KV_en_schnell_ASEANValidator.addValidation("Inpatient",{dontselect:"Inpatient coverage...",message:"Please select an option for inpatient coverage"} );
Anfrage_internationale_KV_en_schnell_ASEANValidator.addValidation("Dental",{dontselect:"Dental coverage...",message:"Please select an option for dental coverage"} );
Anfrage_internationale_KV_en_schnell_ASEANValidator.addValidation("Checkups",{dontselect:"Check-ups...",message:"Please select an option for Checkups"} );
Anfrage_internationale_KV_en_schnell_ASEANValidator.addValidation("Maternity",{dontselect:"Maternity coverage...",message:"Please select an option for Maternity",condition:function(){ return sfm_condition_check('is_selected(GenderVP1,"female")','Anfrage_internationale_KV_en_schnell_ASEAN')}} );
Anfrage_internationale_KV_en_schnell_ASEANValidator.addValidation("Deductible",{dontselect:"Annual deductible...",message:"Please select an option for Deductible"} );
Anfrage_internationale_KV_en_schnell_ASEANValidator.addValidation("FirstNameVP1",{required:true,message:"Please fill in the first name of the first person to be insured."} );
Anfrage_internationale_KV_en_schnell_ASEANValidator.addValidation("LastNameVP1",{required:true,message:"Please fill in the last name of the first person to be insured."} );
Anfrage_internationale_KV_en_schnell_ASEANValidator.addValidation("GenderVP1",{dontselect:"Gender...",message:"Please select the gender of the first person to be insured."} );
Anfrage_internationale_KV_en_schnell_ASEANValidator.addValidation("CitizenshipVP1",{required:true,message:"Please fill in the citizenship(s) of the first person to be insured."} );
Anfrage_internationale_KV_en_schnell_ASEANValidator.addValidation("DoBVP1",{required:true,message:"Please fill in the date of birth of the first person to be insured."} );
Anfrage_internationale_KV_en_schnell_ASEANValidator.addValidation("DoBVP1",{before_date:"SameDay",message:"The date of birth must be in the past."} );
Anfrage_internationale_KV_en_schnell_ASEANValidator.addValidation("Title",{dontselect:"Title...",message:"Please select an option for title"} );
Anfrage_internationale_KV_en_schnell_ASEANValidator.addValidation("FirstName",{required:true,message:"Please insert your first name."} );
Anfrage_internationale_KV_en_schnell_ASEANValidator.addValidation("LastName",{required:true,message:"Please insert your last name."} );
Anfrage_internationale_KV_en_schnell_ASEANValidator.addValidation("Email",{required:true,message:"Please insert your E-Mail address."} );
Anfrage_internationale_KV_en_schnell_ASEANValidator.addValidation("Email",{email:true,message:"Please insert a valid E-Mail address."} );
Anfrage_internationale_KV_en_schnell_ASEANValidator.addValidation("EmailRepeat",{email:true,message:"Please insert your E-Mail address."} );
Anfrage_internationale_KV_en_schnell_ASEANValidator.addValidation("EmailRepeat",{required:true,message:"Please insert a valid E-Mail address."} );
Anfrage_internationale_KV_en_schnell_ASEANValidator.addValidation("EmailRepeat",{eqelmnt:"Email",message:"E-Mail-addresses do not match."} );

// ]]>
      </script>
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</html>