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Application1 copy.aspx
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Application1 copy.aspx
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<%@ Page Language="C#" AutoEventWireup="true" CodeFile="Application1.aspx.cs" Inherits="Application1" %>
<%@ Register TagPrefix="MaskedInput" Namespace="MaskedInput" Assembly="MaskedInput" %>
<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html>
<head>
<title>ePMS | electronic Policy Manager Solution</title>
<meta name="GENERATOR" Content="Microsoft Visual Studio 7.0">
<meta name="CODE_LANGUAGE" Content="C#">
<meta name="vs_defaultClientScript" content="JavaScript">
<meta name="vs_targetSchema" content="http://schemas.microsoft.com/intellisense/ie5">
<link rel="stylesheet" href="css/jquery-ui-1.7.2.custom.css" type="text/css" />
<script type="text/javascript" src="js/jquery-1.3.2.min.js"></script>
<script type="text/javascript" src="js/jquery-ui-1.7.2.custom.min.js"></script>
<script src="js/load.js" type="text/javascript"></script>
<style type="text/css">
.toggler {
width: 276px;
height: 16px;
}
#button {
padding: .5em 2em;
text-decoration: none;
}
#btnCloseEffect {
text-decoration: none;
}
#effect {
width: 455px;
height: 480px;
padding: 0.4em;
position: relative;
}
#effect h3 {
margin: 0;
padding: 0.4em;
text-align: center;
}
.ui-effects-transfer {
border: 2px dotted gray;
}
</style>
<style type="text/css">
#jq-books {
width: 200px;
float: right;
margin-right: 0
}
#jq-books li {
line-height: 1.25em;
margin: 1em 0 1.8em;
clear: left
}
#home-content-wrapper #jq-books a.jq-bookImg {
float: left;
margin-right: 10px;
width: 55px;
height: 70px
}
#jq-books h3 {
margin: 0 0 .2em 0
}
#home-content-wrapper #jq-books h3 a {
font-size: 1em;
color: black;
}
#home-content-wrapper #jq-books a.jq-buyNow {
font-size: 1em;
color: white;
display: block;
background: url(http://static.jquery.com/files/rocker/images/btn_blueSheen.gif) 50% repeat-x;
text-decoration: none;
color: #fff;
font-weight: bold;
padding: .2em .8em;
float: left;
margin-top: .2em;
}
.style4 {
width: 147px;
}
.style5 {
height: 46px;
width: 147px;
}
.style6 {
height: 17px;
width: 147px;
}
.style7 {
height: 19px;
width: 147px;
}
.style8 {
width: 46px;
}
</style>
<script>
function parseRate() {
var myString;
//for(i = 1;i <= document.form1.ddlPolicyClass.options.length ; i++)
//{
//myString = document.form1.ddlPolicyClass.options[1].value;
myString = document.form1.ddlPolicyClass.options[document.form1.ddlPolicyClass.selectedIndex].value;
var myRateList = myString.split("|");
//alert(myRateList[0]+"-"+myRateList[1])
document.form1.txtPrateID.value = myRateList[0];
document.form1.HIIsoCode.value = myRateList[1];
document.form1.HIClass.value = myRateList[2];
document.form1.HIRate1.value = myRateList[3];
document.form1.HIRate2.value = myRateList[4];
document.form1.HIRate3.value = myRateList[5];
document.form1.HIRate4.value = myRateList[6];
document.form1.txtIsoCode.value = myRateList[1];
document.form1.txtClass.value = myRateList[2];
document.form1.txtRate1.value = myRateList[3];
document.form1.txtRate2.value = myRateList[4];
document.form1.txtRate3.value = myRateList[5];
document.form1.txtRate4.value = myRateList[6];
// for(a = 0;a < myRateList.lenght; a++)
// {
// var Rate1 = myRateList[a];
// var startPos = Rate1.indexOf(',');
// var myValue = Rate1.substring(startPos, Rate1.lenght -startPos);
// //alert(myValue);
// document.form1.txtIsoCode.value = myValue;
// }
//}
}
</script>
</head>
<script type="text/javascript" src="js/jquery-1.3.2.min.js"></script>
<script type="text/javascript" src="js/jquery-ui-1.7.2.custom.min.js"></script>
<script type="text/javascript">
$(function() {
$('#<%= txtPriPolEffecDate1.ClientID %>').datepicker({
changeMonth: true,
changeYear: true
});
$('#<%= txtPriPolEffecDate2.ClientID %>').datepicker({
changeMonth: true,
changeYear: true
});
$('#<%= txtPriPolEffecDate3.ClientID %>').datepicker({
changeMonth: true,
changeYear: true
});
$('#<%= txtExcPolEffecDate1.ClientID %>').datepicker({
changeMonth: true,
changeYear: true
});
$('#<%= txtExcPolEffecDate2.ClientID %>').datepicker({
changeMonth: true,
changeYear: true
});
$('#<%= txtExcPolEffecDate3.ClientID %>').datepicker({
changeMonth: true,
changeYear: true
});
$('#<%= txtDateBirth.ClientID %>').datepicker({
changeMonth: true,
changeYear: true
});
$('#<%= txtPrimaryRetroDate.ClientID %>').datepicker({
changeMonth: true,
changeYear: true
});
$('#<%= txtExcessRetroDate.ClientID %>').datepicker({
changeMonth: true,
changeYear: true
});
});
function ShowDateTimePicker() {
$('#<%= txtPriPolEffecDate1.ClientID %>').datepicker('show');
}
function ShowDateTimePicker2() {
$('#<%= txtPriPolEffecDate2.ClientID %>').datepicker('show');
}
function ShowDateTimePicker3() {
$('#<%= txtPriPolEffecDate3.ClientID %>').datepicker('show');
}
function ShowDateTimePicker4() {
$('#<%= txtExcPolEffecDate1.ClientID %>').datepicker('show');
}
function ShowDateTimePicker5() {
$('#<%= txtExcPolEffecDate2.ClientID %>').datepicker('show');
}
function ShowDateTimePicker6() {
$('#<%= txtExcPolEffecDate3.ClientID %>').datepicker('show');
}
function ShowDateTimePicker7() {
$('#<%= txtDateBirth.ClientID %>').datepicker('show');
}
function ShowDateTimePicker8() {
$('#<%= txtPrimaryRetroDate.ClientID %>').datepicker('show');
}
//style="width: 316px; display:none"
function pageLoad() {
//sets initial state of the contactfinderdiv
//alert(jQuery('#HIState').val());
var state = jQuery('#HIState').val();
if (state == '1') {
$('#effect').css('display', 'block');
//$('#HIState').val('');
} else {
$('#effect').css('display', 'none');
}
$('.btnRate').click(function() {
$('.togglebox').show('slow');
});
$('.btnCloseEffect').click(function() {
$('.togglebox').hide('slow');
});
}
$(function() {
//run the currently selected effect
function runEffect() {
//get effect type from
//var selectedEffect = $('#effectTypes').val();
$('#HIState').val('1');
var selectedEffect = "blind";
//most effect types need no options passed by default
var options = {};
//run the effect
$("#effect").show(selectedEffect, options, 500, callback);
};
//callback function to bring a hidden box back
function callback() {
// setTimeout(function()
// {
// $("#effect:visible").removeAttr('style').hide().fadeOut();
// },
// 1000);
};
function CloseEffect() {
setTimeout(function() {
$('#HIState').val('0');
$("#effect:visible").removeAttr('style').hide().fadeOut();
},
10);
}
//set effect from select menu value
$("#button").click(function() {
runEffect();
return false;
});
$("#btnRate").click(function() {
runEffect();
return false;
});
$("#btnCloseEffect").click(function() {
CloseEffect();
return false;
});
$("#effect").hide();
});
</script>
<body onload="pageLoad()">
<form id="form1" runat="server">
<div>
<table id="Table8" align="center" bgcolor="white" border="0" cellpadding="0" cellspacing="0" style="z-index: 139; left: 4px; width: 100%; position: static;
top: 4px; height: 1px" width="921">
<tr>
<td colspan="3" style="width: 764px; height: 1px">
<p>
<asp:PlaceHolder ID="Placeholder1" runat="server"></asp:PlaceHolder>
</p>
</td>
</tr>
<tr>
<td align="center" style="font-size: 0pt; width: 86px; height: 396px">
<table id="Table9" bgcolor="white" border="0" cellpadding="0" cellspacing="0" style="width: 819px;
height: 64px" width="819">
<tr>
<td style="font-size: 0pt; " valign="top" class="style4">
<table id="Table11" border="0" cellpadding="0" cellspacing="0" style="width: 808px" width="808">
<tr>
<td class="style8" rowspan="2">
<asp:Label ID="Label21" runat="server" Font-Bold="True" Font-Names="Tahoma" Font-Size="11pt" ForeColor="Black" Height="16px" Width="92px">Application:</asp:Label>
<asp:Label ID="lblTaskControlID" runat="server" Font-Names="Tahoma" Font-Size="9pt" Width="124px"></asp:Label>
</td>
<td>
<%--Se movieron los botones Convert Primary y Convert Excess--%>
<asp:Button ID="btnConvert" runat="server" BackColor="#400000" BorderColor="#400000" BorderWidth="0px" Font-Names="Tahoma" ForeColor="White" Height="23px" Text="Convert Excess" Width="125px" OnClick="btnConvert_Click" TabIndex="1" style="margin-right: 1px"
/> </td>
<td align="right">
<asp:Button ID="btnPrint" runat="server" BackColor="#400000" BorderColor="#400000" BorderWidth="0px" Font-Names="Tahoma" ForeColor="White" Height="23px" Text="Print Quote" Width="80px" OnClick="btnPrint_Click" TabIndex="2" style="margin-right: 1px; margin-bottom: 1px;"
/>
</td>
</tr>
<tr>
<%--Se movi� de �sta �rea el bot�n Convert Excess al lado izquierdo del bot�n Convert Primary--%>
<td>
<asp:Button ID="btnConvertPrimary" runat="server" BackColor="#400000" BorderColor="#400000" BorderWidth="0px" Font-Names="Tahoma" ForeColor="White" Height="23px" Text="Convert Primary" Width="125px" OnClick="btnConvertPrimary_Click" TabIndex="1" style="margin-right: 1px; margin-bottom: 1px;"
/>
</td>
<td align="right">
<asp:Button ID="btnRate" runat="server" Text="Rate" BackColor="#400000" BorderColor="#400000" BorderWidth="0px" Font-Names="Tahoma" ForeColor="White" Height="23px" TabIndex="69" Width="65px" style="margin-right: 1px" />
<asp:Button ID="BtnSave" runat="server" BackColor="#400000" BorderColor="#400000" BorderWidth="0px" Font-Names="Tahoma" ForeColor="White" Height="23px" OnClick="BtnSave_Click" TabIndex="70" Text="Save" Width="65px" style="margin-right: 1px" />
<asp:Button ID="btnEdit" runat="server" BackColor="#400000" BorderColor="#400000" BorderWidth="0px" Font-Names="Tahoma" ForeColor="White" Height="23px" Text="Modify" Width="65px" OnClick="btnEdit_Click" TabIndex="4" style="margin-right: 1px" />
<asp:Button ID="btnDelete" runat="server" BackColor="#400000" BorderColor="#400000" BorderWidth="0px" Font-Names="Tahoma" ForeColor="White" Height="23px" Text="Delete" Width="65px" OnClick="btnDelete_Click" TabIndex="1" style="margin-right: 1px" />
<asp:Button ID="btnCancel" runat="server" BackColor="#400000" BorderColor="#400000" BorderWidth="0px" Font-Names="Tahoma" ForeColor="White" Height="23px" Text="Cancel" Width="65px" OnClick="btnCancel_Click" TabIndex="3" style="margin-right: 1px" />
<asp:Button ID="BtnExit" runat="server" BackColor="#400000" BorderColor="#400000" BorderWidth="0px" Font-Names="Tahoma" ForeColor="White" Height="23px" Text="Exit" Width="65px" OnClick="BtnExit_Click" TabIndex="5" />
</td>
</tr>
<tr>
<td colspan="3" align="center">
<div class="toggler" align="center">
<div id="effect" class="ui-widget-header ui-corner-all" style="width: 453px; display:none">
<asp:Panel ID="Panel1" runat="server">
<table style="width: 244px; font-size: 9pt;" border="1">
<tr>
<td align="center" colspan="5" height="16">
<asp:Label ID="Label49" runat="server" Font-Bold="True" Font-Names="Tahoma" Font-Size="14pt" Font-Underline="True" Text="Select Rate" Width="116px"></asp:Label>
</td>
</tr>
<tr>
<td align="center" colspan="5" height="16">
<asp:RadioButton ID="RadioButton1" runat="server" Text="Primary" AutoPostBack="True" OnCheckedChanged="RadioButton1_CheckedChanged" />
<asp:RadioButton ID="RadioButton2" runat="server" Text="Excess" AutoPostBack="True" OnCheckedChanged="RadioButton2_CheckedChanged" />
</td>
</tr>
<tr>
<td height="14" align="right">
<asp:Label ID="Label51" runat="server" Font-Names="Tahoma" Font-Size="9pt" Text="Primary Retro Date:" Width="129px"></asp:Label>
</td>
<td height="14" style="width: 155px">
<MaskedInput:MaskedTextBox ID="txtPrimaryRetroDate" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px" IsDate="True" onclick="ShowDateTimePicker8();" TabIndex="11" Width="66px" AutoPostBack="True" OnTextChanged="txtPrimaryRetroDate_TextChanged"></MaskedInput:MaskedTextBox>
</td>
<td height="14" align="right" colspan="2">
<asp:Label ID="Label56" runat="server" Font-Names="Tahoma" Font-Size="9pt" Text="Excess Retro Date:" Width="119px"></asp:Label>
</td>
<td height="14" style="width: 83px">
<MaskedInput:MaskedTextBox ID="txtExcessRetroDate" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px" IsDate="True" onclick="ShowDateTimePicker9();" TabIndex="11" Width="66px" AutoPostBack="True" OnTextChanged="txtExcessRetroDate_TextChanged"></MaskedInput:MaskedTextBox>
</td>
</tr>
<tr>
<td align="right" colspan="5" height="14">
</td>
</tr>
<tr>
<td height="14">
<asp:Label ID="Label63" runat="server" Font-Bold="True" Font-Names="Tahoma" Font-Size="10pt" Text="Primary Rate" Width="120px"></asp:Label>
</td>
<td height="14" style="width: 155px">
<asp:Label ID="Label65" runat="server" Font-Names="Tahoma" Font-Size="9pt" Text="Rate 1" Width="44px"></asp:Label>
</td>
<td height="14" style="width: 83px">
<asp:Label ID="Label66" runat="server" Font-Names="Tahoma" Font-Size="9pt" Text="Rate 2" Width="48px"></asp:Label>
</td>
<td height="14" style="width: 83px">
<asp:Label ID="Label67" runat="server" Font-Names="Tahoma" Font-Size="9pt" Text="Rate 3" Width="44px"></asp:Label>
</td>
<td height="14" style="width: 83px">
<asp:Label ID="Label68" runat="server" Font-Names="Tahoma" Font-Size="9pt" Text="MCM Rate " Width="68px"></asp:Label>
</td>
</tr>
<tr>
<td height="14">
<asp:DropDownList ID="ddlPrimaryLimits1" runat="server" Font-Names="Tahoma" Font-Size="8.5pt" Height="20px" TabIndex="1" Width="136px" AutoPostBack="True" OnSelectedIndexChanged="ddlPrimaryLimits1_SelectedIndexChanged" ForeColor="Black">
</asp:DropDownList>
</td>
<td height="14" style="width: 155px">
<asp:TextBox ID="txtPRate1" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px" ReadOnly="True" TabIndex="8" Width="64px"></asp:TextBox>
</td>
<td height="14" style="width: 83px">
<asp:TextBox ID="txtPRate2" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px" TabIndex="8" Width="64px"></asp:TextBox>
</td>
<td height="14" style="width: 83px">
<asp:TextBox ID="txtPRate3" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px" TabIndex="8" Width="64px"></asp:TextBox>
</td>
<td height="14" style="width: 83px">
<asp:TextBox ID="txtPRate4" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px" TabIndex="8" Width="64px"></asp:TextBox>
</td>
</tr>
<tr>
<td height="14" colspan="5">
</td>
</tr>
<tr>
<td height="14">
<asp:Label ID="Label64" runat="server" Font-Names="Tahoma" Font-Size="10pt" Text="Excess Rate" Width="107px" Font-Bold="True"></asp:Label>
</td>
<td style="width: 155px" height="14">
<asp:Label ID="Label42" runat="server" Font-Names="Tahoma" Font-Size="9pt" Text="Rate 1" Width="44px"></asp:Label>
</td>
<td height="14" style="width: 83px">
<asp:Label ID="Label43" runat="server" Font-Names="Tahoma" Font-Size="9pt" Text="Rate 2" Width="48px"></asp:Label>
</td>
<td style="width: 83px" height="14">
<asp:Label ID="Label45" runat="server" Font-Names="Tahoma" Font-Size="9pt" Text="Rate 3" Width="44px"></asp:Label>
</td>
<td height="14" style="width: 83px">
<asp:Label ID="Label44" runat="server" Font-Names="Tahoma" Font-Size="9pt" Text="MCM Rate " Width="68px"></asp:Label>
</td>
</tr>
<tr>
<td height="14">
<asp:DropDownList ID="ddlLimits" runat="server" Font-Names="Tahoma" Font-Size="8.5pt" Height="20px" TabIndex="1" Width="136px" AutoPostBack="True" OnSelectedIndexChanged="ddlLimits_SelectedIndexChanged">
</asp:DropDownList>
</td>
<td style="width: 155px" height="14">
<asp:TextBox ID="txtRate1" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px" TabIndex="8" Width="64px"></asp:TextBox>
</td>
<td height="14" style="width: 32px">
<asp:TextBox ID="txtRate2" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px" TabIndex="8" Width="64px"></asp:TextBox>
</td>
<td style="width: 83px" height="14">
<asp:TextBox ID="txtRate3" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px" TabIndex="8" Width="64px"></asp:TextBox>
</td>
<td height="14" style="width: 83px">
<asp:TextBox ID="txtRate4" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px" TabIndex="8" Width="64px"></asp:TextBox>
</td>
</tr>
<tr>
<td colspan="5" height="14">
<asp:Label ID="Label62" runat="server" Font-Names="Tahoma" Font-Size="9pt" Text="Others Excess Rates:" Width="200px"></asp:Label>
</td>
</tr>
<tr>
<td height="14">
<asp:DropDownList ID="ddlLimits2" runat="server" Font-Names="Tahoma" Font-Size="8.5pt" Height="20px" TabIndex="1" Width="136px" AutoPostBack="True" OnSelectedIndexChanged="ddlLimits_SelectedIndexChanged" ForeColor="Black">
</asp:DropDownList>
</td>
<td height="14" style="width: 155px">
<asp:TextBox ID="txtRate12" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px" ReadOnly="True" TabIndex="8" Width="64px"></asp:TextBox>
</td>
<td height="14" style="width: 32px">
<asp:TextBox ID="txtRate22" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px" ReadOnly="True" TabIndex="8" Width="64px"></asp:TextBox>
</td>
<td height="14" style="width: 83px">
<asp:TextBox ID="txtRate32" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px" ReadOnly="True" TabIndex="8" Width="64px"></asp:TextBox>
</td>
<td height="14" style="width: 83px">
<asp:TextBox ID="txtRate42" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px" ReadOnly="True" TabIndex="8" Width="64px"></asp:TextBox>
</td>
</tr>
<tr>
<td height="14">
<asp:DropDownList ID="ddlLimits3" runat="server" Font-Names="Tahoma" Font-Size="8.5pt" Height="20px" TabIndex="1" Width="136px" AutoPostBack="True" ForeColor="Black">
</asp:DropDownList>
</td>
<td height="14" style="width: 155px">
<asp:TextBox ID="txtRate13" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px" ReadOnly="True" TabIndex="8" Width="64px"></asp:TextBox>
</td>
<td height="14" style="width: 32px">
<asp:TextBox ID="txtRate23" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px" ReadOnly="True" TabIndex="8" Width="64px"></asp:TextBox>
</td>
<td height="14" style="width: 83px">
<asp:TextBox ID="txtRate33" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px" ReadOnly="True" TabIndex="8" Width="64px"></asp:TextBox>
</td>
<td height="14" style="width: 83px">
<asp:TextBox ID="txtRate43" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px" ReadOnly="True" TabIndex="8" Width="64px"></asp:TextBox>
</td>
</tr>
<tr>
<td height="14">
<asp:DropDownList ID="ddlLimits4" runat="server" Font-Names="Tahoma" Font-Size="8.5pt" Height="20px" TabIndex="1" Width="136px" AutoPostBack="True" ForeColor="Black" OnSelectedIndexChanged="ddlLimits4_SelectedIndexChanged">
</asp:DropDownList>
</td>
<td height="14" style="width: 155px">
<asp:TextBox ID="txtRate14" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px" ReadOnly="True" TabIndex="8" Width="64px"></asp:TextBox>
</td>
<td height="14" style="width: 32px">
<asp:TextBox ID="txtRate24" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px" ReadOnly="True" TabIndex="8" Width="64px"></asp:TextBox>
</td>
<td height="14" style="width: 83px">
<asp:TextBox ID="txtRate34" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px" ReadOnly="True" TabIndex="8" Width="64px"></asp:TextBox>
</td>
<td height="14" style="width: 83px">
<asp:TextBox ID="txtRate44" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px" ReadOnly="True" TabIndex="8" Width="64px"></asp:TextBox>
</td>
</tr>
<tr>
<td height="14">
<asp:DropDownList ID="ddlLimits5" runat="server" Font-Names="Tahoma" Font-Size="8.5pt" Height="20px" TabIndex="1" Width="136px" AutoPostBack="True" ForeColor="Black">
</asp:DropDownList>
</td>
<td height="14" style="width: 155px">
<asp:TextBox ID="txtRate15" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px" ReadOnly="True" TabIndex="8" Width="64px"></asp:TextBox>
</td>
<td height="14" style="width: 32px">
<asp:TextBox ID="txtRate25" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px" ReadOnly="True" TabIndex="8" Width="64px"></asp:TextBox>
</td>
<td height="14" style="width: 83px">
<asp:TextBox ID="txtRate35" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px" ReadOnly="True" TabIndex="8" Width="64px"></asp:TextBox>
</td>
<td height="14" style="width: 83px">
<asp:TextBox ID="txtRate45" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px" ReadOnly="True" TabIndex="8" Width="64px"></asp:TextBox>
</td>
</tr>
<tr>
<td height="14">
<asp:DropDownList ID="ddlLimits6" runat="server" Font-Names="Tahoma" Font-Size="8.5pt" Height="20px" TabIndex="1" Width="136px" AutoPostBack="True" ForeColor="Black">
</asp:DropDownList>
</td>
<td height="14" style="width: 155px">
<asp:TextBox ID="txtRate16" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px" ReadOnly="True" TabIndex="8" Width="64px"></asp:TextBox>
</td>
<td height="14" style="width: 32px">
<asp:TextBox ID="txtRate26" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px" ReadOnly="True" TabIndex="8" Width="64px"></asp:TextBox>
</td>
<td height="14" style="width: 83px">
<asp:TextBox ID="txtRate36" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px" ReadOnly="True" TabIndex="8" Width="64px"></asp:TextBox>
</td>
<td height="14" style="width: 83px">
<asp:TextBox ID="txtRate46" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px" ReadOnly="True" TabIndex="8" Width="64px"></asp:TextBox>
</td>
</tr>
<tr>
<td height="14" colspan="5">
</td>
</tr>
<tr>
<td height="14">
<asp:Label ID="Label41" runat="server" Font-Names="Tahoma" Font-Size="9pt" Text="Select Specialty:" Width="117px"></asp:Label>
</td>
<td align="left" height="14" style="width: 83px" colspan="4">
<asp:DropDownList ID="ddlPolicyClass" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="20px" TabIndex="1" Width="228px" OnSelectedIndexChanged="ddlPolicyClass_SelectedIndexChanged1" AutoPostBack="True">
</asp:DropDownList>
</td>
</tr>
<tr>
<td height="14" colspan="5">
<asp:DropDownList ID="ddPrimarylPolicyClass" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="20px" TabIndex="1" Width="228px" AutoPostBack="True" OnSelectedIndexChanged="ddPrimarylPolicyClass_SelectedIndexChanged" Visible="False">
</asp:DropDownList>
</td>
</tr>
<tr>
<td colspan="1" height="14">
<asp:Label ID="Label46" runat="server" Font-Names="Tahoma" Font-Size="9pt" Text="Iso Code:" Width="64px"></asp:Label>
</td>
<td colspan="2" height="14">
<asp:TextBox ID="txtIsoCode" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px" TabIndex="8" Width="68px" ReadOnly="True"></asp:TextBox>
</td>
<td align="center" height="14" style="width: 83px">
<asp:Label ID="Label47" runat="server" Font-Names="Tahoma" Font-Size="9pt" Text="Class:" Width="64px"></asp:Label>
</td>
<td align="center" height="14" style="width: 83px">
<asp:TextBox ID="txtClass" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px" TabIndex="8" Width="68px" ReadOnly="True"></asp:TextBox>
</td>
</tr>
<tr>
<td colspan="4" height="14">
</td>
<td align="center" height="14" style="width: 83px">
<asp:Button ID="btnCloseEffect" runat="server" Text="Close" BackColor="#400000" BorderColor="#400000" BorderWidth="0px" Font-Names="Tahoma" Font-Size="9pt" ForeColor="White" Height="23px" Width="60px" />
</td>
</tr>
</table>
</asp:Panel>
</div>
</div>
</td>
</tr>
</table>
</td>
</tr>
<tr>
<td align="center" style="font-size: 2pt; " valign="middle" class="style5">
<table id="Table6" border="0" cellpadding="0" cellspacing="0" style="width: 811px;
height: 112px" width="811">
<tr>
<td align="center" style="font-size: 1pt; height: 169px;" valign="top">
<table id="Table1" border="0" cellpadding="0" cellspacing="0" style="width: 100%;
height: 1px" width="806">
<tr>
<td style="width: 8px; height: 11px">
</td>
<td style="width: 200px; height: 11px" align="left" colspan="2">
<asp:Label ID="Label2" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="6px" Width="176px" Font-Bold="True">I. PERSONAL INFORMATION</asp:Label>
</td>
<td style="width: 15%; height: 11px" align="left">
<asp:Label ID="Label1" runat="server" EnableViewState="False" Font-Names="Tahoma" Font-Size="9pt" Height="18px" Width="80px">Customer No.:</asp:Label>
</td>
<td style="width: 330px; height: 11px" align="left">
<asp:TextBox ID="TxtCustomerNo" runat="server" Height="12px" Width="108px" Font-Names="Tahoma" Font-Size="9pt"></asp:TextBox>
<asp:Button ID="btnNextTop" runat="server" BackColor="#400000" BorderColor="#400000" BorderWidth="0px" Font-Names="Tahoma" ForeColor="White" Height="23px" Text="Next >" Width="54px" OnClick="btnNextTop_Click" TabIndex="6" Visible="False" />
</td>
</tr>
<tr>
<td style="width: 8px; height: 11px">
</td>
<td align="left" colspan="2" style="width: 280px; height: 11px">
</td>
<td align="left" style="width: 15%; height: 11px">
<asp:Label ID="Label50" runat="server" EnableViewState="False" Font-Names="Tahoma" Font-Size="9pt" Height="18px" Width="80px">Status:</asp:Label>
</td>
<td align="left" style="width: 330px; height: 11px">
<asp:DropDownList ID="ddlStatus" runat="server" Height="21px" Width="276px" Font-Names="Tahoma" Font-Size="9pt" TabIndex="52">
</asp:DropDownList>
</td>
</tr>
<tr>
<td style="width: 8px; height: 11px">
</td>
<td align="left" colspan="2" style="width: 280px; height: 11px">
</td>
<td align="left" style="width: 15%; height: 11px">
<asp:Label ID="Label52" runat="server" EnableViewState="False" Font-Names="Tahoma" Font-Size="9pt" Height="18px" Width="56px">Agency:</asp:Label>
</td>
<td align="left" style="width: 330px; height: 11px">
<asp:DropDownList ID="ddlAgency" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="19px" TabIndex="52" Width="276px">
</asp:DropDownList>
</td>
</tr>
<tr>
<td style="width: 8px; height: 11px">
</td>
<td align="left" colspan="2" style="width: 280px; height: 11px">
</td>
<td align="left" style="width: 15%; height: 11px">
<asp:Label ID="Label53" runat="server" CssClass="headfield1" EnableViewState="False" Font-Names="Tahoma" Font-Size="9pt" Height="14px" Width="40px">Agent:</asp:Label>
</td>
<td align="left" style="width: 330px; height: 11px">
<asp:DropDownList ID="ddlAgent" runat="server" CssClass="headfield1" Font-Names="Tahoma" Font-Size="8pt" Height="19px" TabIndex="52" Width="276px">
</asp:DropDownList>
</td>
</tr>
<tr>
<td style="width: 8px; height: 10px">
</td>
<td style="width: 19%; height: 10px" align="left">
<asp:Label ID="Label54" runat="server" CssClass="headfield1" EnableViewState="False" Font-Names="Tahoma" Font-Size="10pt" ForeColor="Red" Height="2px" Width="1px">*</asp:Label>
<asp:Label ID="lblGender" runat="server" CssClass="headfield1" EnableViewState="False" Font-Names="Tahoma" Font-Size="9pt" Height="2px">Name: Dr (a).</asp:Label>
</td>
<td align="left" style="width: 186px; height: 10px">
<asp:TextBox ID="TxtFirstName" runat="server" Height="12px" Width="164px" Font-Names="Tahoma" Font-Size="9pt" TabIndex="7"></asp:TextBox>
</td>
<td style="width: 15%; height: 10px" align="left">
</td>
<td style="width: 331px; height: 10px" align="left">
</td>
</tr>
<tr>
<td style="width: 8px; height: 15px">
</td>
<td style="width: 19%; height: 11px" align="left">
<asp:Label ID="lblLastName2" runat="server" CssClass="headfield1" EnableViewState="False" Font-Names="Tahoma" Font-Size="9pt" Height="2px" Width="36px">Middle:</asp:Label>
</td>
<td align="left" style="width: 186px; height: 11px">
<asp:TextBox ID="TxtInitial" runat="server" Height="12px" Width="24px" Font-Names="Tahoma" Font-Size="9pt" TabIndex="8"></asp:TextBox>
</td>
<td style="width: 15%; height: 11px" align="left">
<asp:Label ID="Label6" runat="server" CssClass="headfield1" Font-Names="Tahoma" Font-Size="9pt" Height="17px" Width="88px">Office Address:</asp:Label>
</td>
<td style="width: 273px; height: 15px" colspan="1" align="left">
<asp:TextBox ID="TxtAddrs1" runat="server" Height="12px" Width="312px" Font-Names="Tahoma" Font-Size="9pt" TabIndex="15"></asp:TextBox>
</td>
</tr>
<tr>
<td style="width: 8px; height: 14px">
</td>
<td style="width: 19%; height: 14px" align="left">
<asp:Label ID="Label55" runat="server" CssClass="headfield1" EnableViewState="False" Font-Names="Tahoma" Font-Size="10pt" ForeColor="Red" Height="2px" Width="1px">*</asp:Label>
<asp:Label ID="lblBirthdate" runat="server" CssClass="headfield1" EnableViewState="False" Font-Names="Tahoma" Font-Size="9pt" Height="18px" Width="52px">LastName:</asp:Label>
</td>
<td align="left" style="width: 186px; height: 11px">
<asp:TextBox ID="txtLastname1" runat="server" Height="12px" Width="164px" Font-Names="Tahoma" Font-Size="9pt" TabIndex="9"></asp:TextBox>
</td>
<td style="width: 15%; height: 14px" align="left">
</td>
<td colspan="1" style="width: 240px; height: 14px" align="left">
<asp:TextBox ID="TxtAddrs2" runat="server" Height="12px" Width="312px" Font-Names="Tahoma" Font-Size="9pt" TabIndex="16"></asp:TextBox>
</td>
</tr>
<tr>
<td style="width: 8px; height: 11px">
</td>
<td style="width: 19%; height: 11px" align="left">
<asp:Label ID="Label4" runat="server" CssClass="headfield1" EnableViewState="False" Font-Names="Tahoma" Font-Size="9pt" Height="18px" Width="60px">LastName2:</asp:Label>
</td>
<td style="width: 186px; height: 11px" align="left">
<asp:TextBox ID="txtLastname2" runat="server" Height="12px" Width="164px" Font-Names="Tahoma" Font-Size="9pt" TabIndex="10"></asp:TextBox>
</td>
<td style="width: 15%; height: 11px" align="left">
<asp:Label ID="Label7" runat="server" CssClass="headfield1" Font-Names="Tahoma" Font-Size="9pt" Height="17px" Width="44px">City:</asp:Label>
</td>
<td style="width: 331px; height: 11px" align="left">
<asp:TextBox ID="TxtCity" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px" Width="180px" TabIndex="17"></asp:TextBox>
<asp:TextBox ID="TxtState" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px" Width="16px" TabIndex="18"></asp:TextBox>
<MaskedInput:MaskedTextBox ID="TxtZip" runat="server" CssClass="headfield1" Font-Names="Tahoma" Font-Size="9pt" Height="12px" IsDate="False" Mask="99999Z9999" MaxLength="10" TabIndex="19" Width="96px"></MaskedInput:MaskedTextBox>
</td>
</tr>
<tr>
<td style="width: 8px; height: 11px">
</td>
<td style="width: 19%; height: 11px" align="left">
<asp:Label ID="lblMaritalStatus" runat="server" CssClass="headfield1" EnableViewState="False" Font-Names="Tahoma" Font-Size="9pt" Height="1px" Width="76px">Date of Birth:</asp:Label>
</td>
<td align="left" style="width: 186px; height: 11px">
<MaskedInput:MaskedTextBox ID="txtDateBirth" runat="server" onclick="ShowDateTimePicker7();" CssClass="headfield1" Font-Names="Tahoma" Font-Size="9pt" Height="12px" IsDate="True" TabIndex="11" Width="84px"></MaskedInput:MaskedTextBox>
</td>
<td align="left" style="width: 15%; height: 11px">
<asp:Label ID="Label59" runat="server" EnableViewState="False" Font-Names="Tahoma" Font-Size="10pt" ForeColor="Red" Height="2px" Width="1px">*</asp:Label>
<asp:Label ID="Label3" runat="server" EnableViewState="False" Font-Names="Tahoma" Font-Size="9pt" Height="2px" Width="84px">Office Phone:</asp:Label>
</td>
<td align="left" style="width: 331px; height: 11px">
<MaskedInput:MaskedTextBox ID="txtWorkPhone" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px" IsCurrency="False" IsDate="False" IsZipCode="False" Mask="(999) 999-9999" TabIndex="20" Width="100px" MaxLength="14"></MaskedInput:MaskedTextBox>
</td>
</tr>
<tr>
<td style="width: 8px; height: 10px">
</td>
<td style="width: 19%; height: 11px" align="left">
<asp:Label ID="lblComments" runat="server" EnableViewState="False" Font-Names="Tahoma" Font-Size="9pt" Height="9px" Width="80px">Place of Birth:</asp:Label>
</td>
<td align="left" style="width: 186px; height: 11px">
<asp:TextBox ID="txtBirthPlace" runat="server" Height="12px" Width="164px" Font-Names="Tahoma" Font-Size="9pt" TabIndex="12"></asp:TextBox>
</td>
<td style="width: 15%; height: 11px" align="left">
<asp:Label ID="lblLastName1" runat="server" EnableViewState="False" Font-Names="Tahoma" Font-Size="9pt" Height="2px" Width="60px">Office Fax:</asp:Label>
</td>
<td style="width: 331px; height: 10px" align="left">
<MaskedInput:MaskedTextBox ID="TxtCellular" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="12px" IsCurrency="False" IsDate="False" IsZipCode="False" Mask="(999) 999-9999" TabIndex="21" Width="100px" MaxLength="14"></MaskedInput:MaskedTextBox>
</td>
</tr>
<tr>
<td style="width: 8px;">
</td>
<td style="width: 19%;" align="left">
<asp:Label ID="lblSocialSecurity" runat="server" CssClass="headfield1" EnableViewState="False" Font-Names="Tahoma" Font-Size="9pt" Height="18px" Width="89px" Visible="False">Social Security:</asp:Label>
</td>
<td style="width: 186px;" align="left">
<MaskedInput:MaskedTextBox ID="txtSocialSecurity" runat="server" CssClass="headfield1" Font-Names="Tahoma" Font-Size="9pt" Height="12px" IsCurrency="False" IsDate="False" IsZipCode="False" Mask="999-99-9999" TabIndex="13" Width="84px" Visible="False"></MaskedInput:MaskedTextBox>
</td>
<td style="width: 15%;" align="left">
<asp:Label ID="Label5" runat="server" CssClass="headfield1" EnableViewState="False" Font-Names="Tahoma" Font-Size="9pt" Height="18px" Width="40px">E-mail:</asp:Label>
</td>
<td colspan="1" style="width: 331px;" align="left">
<asp:TextBox ID="txtEmail" runat="server" Height="12px" Width="312px" Font-Names="Tahoma" Font-Size="9pt" TabIndex="22"></asp:TextBox>
</td>
</tr>
<tr>
<td style="width: 8px; height: 16px">
</td>
<td align="left" style="width: 19%; height: 16px">
<asp:Label ID="lblHouseIncome" runat="server" CssClass="headfield1" Font-Names="Tahoma" Font-Size="9pt" Height="17px" Width="56px">Gender:</asp:Label>
</td>
<td align="left" style="width: 186px; height: 16px">
<asp:RadioButtonList ID="rdoGender" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="1px" RepeatDirection="Horizontal" Width="80px" TabIndex="14">
<asp:ListItem>Female</asp:ListItem>
<asp:ListItem>Male</asp:ListItem>
</asp:RadioButtonList>
</td>
<td align="left" style="width: 15%; height: 16px">
<asp:Label ID="Label61" runat="server" CssClass="headfield1" EnableViewState="False" Font-Names="Tahoma" Font-Size="10pt" ForeColor="Red" Height="2px" Width="1px">*</asp:Label>
<asp:Label ID="Label8" runat="server" CssClass="headfield1" EnableViewState="False" Font-Names="Tahoma" Font-Size="9pt" Height="18px" Width="76px">Cell Phone:</asp:Label>
</td>
<td align="left" colspan="1" style="width: 331px; height: 16px">
<MaskedInput:MaskedTextBox ID="txtHomePhone" runat="server" CssClass="headfield1" Font-Names="Tahoma" Font-Size="9pt" Height="12px" IsCurrency="False" IsDate="False" IsZipCode="False" Mask="(999) 999-9999" TabIndex="23" Width="100px" MaxLength="14"></MaskedInput:MaskedTextBox>
</td>
</tr>
<tr>
<td style="width: 8px; height: 16px">
</td>
<td align="left" style="width: 19%; height: 16px">
</td>
<td align="left" style="width: 186px; height: 16px">
</td>
<td align="left" style="width: 15%; height: 16px">
<asp:Label ID="Label151" runat="server" CssClass="headfield1" Font-Names="Tahoma" Font-Size="9pt" Height="17px" Width="40px">License:</asp:Label>
</td>
<td align="left" colspan="1" style="width: 331px; height: 16px">
<asp:TextBox ID="txtLicense" runat="server" CssClass="headfield1" Font-Names="Tahoma" Font-Size="9pt" Height="12px" MaxLength="25" TabIndex="15" Width="138px"></asp:TextBox>
</td>
</tr>
<tr>
<td style="width: 8px; height: 16px">
</td>
<td align="left" style="width: 19%; height: 16px">
<asp:Label ID="Label48" runat="server" CssClass="headfield1" Font-Names="Tahoma" Font-Size="9pt" Height="17px" Width="56px">Comments:</asp:Label>
</td>
<td align="left" colspan="3" style="width: 600px; height: 16px">
<asp:TextBox ID="txtComments" runat="server" Font-Names="Tahoma" Font-Size="9pt" Height="48px" TabIndex="22" TextMode="MultiLine" Width="508px"></asp:TextBox>
</td>
</tr>
<%--<tr>
<td background="Images2/Barra3.jpg" colspan="5" style="width: 8px; height: 4px">
</td>
</tr>--%>
</table>
</td>
</tr>
</table>
</td>
</tr>
<tr>
<td align="left" colspan="1" style="font-size: 5pt; " valign="top" class="style6">
</td>
</tr>
<tr>
<td style="font-size: 0pt; " class="style7">
<table id="Table3" border="0" cellpadding="1" cellspacing="1" style="width: 814px;
height: 76px" width="814">
<tr>
<td align="left" style="font-size: 1pt; height: 258px;" valign="top">
<table id="Table4" border="0" cellpadding="0" cellspacing="0" style="width: 808px;
height: 1px">
<tr>
<td colspan="1" style="width: 211px">
<asp:Label ID="lblTypeAddress1" runat="server" CssClass="headform3" Font-Bold="True" Font-Names="Tahoma" Font-Size="9pt" Width="155px">II. INSURANCE HISTORY</asp:Label>
</td>
<td style="width: 206px">
</td>
<td style="width: 154px">
</td>
<td style="width: 321px">
</td>
</tr>
<tr>
<td align="left" colspan="5" style="width: 700px; height: 14px;">
<asp:Label ID="Label15" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma" Font-Size="9pt" Width="636px">2. Please provide the necessary information below with respect to your primary insurance coverage for</asp:Label>
</td>
</tr>
<tr>
<td align="left" colspan="5" style="width: 720px; height: 14px;">
<asp:Label ID="Label17" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma" Font-Size="9pt" Width="636px">the last three years, including the coverage in force as of the date of this application.</asp:Label>
</td>
</tr>
<tr>
<td colspan="7" style="font-size: 5pt; width: 400px; height: 7px">
</td>
</tr>
<tr>
<td align="center" style="width: 211px" colspan="" bordercolor="silver">
<asp:Label ID="Label18" runat="server" CssClass="headfield1" EnableViewState="False" Font-Names="Tahoma" Font-Size="9pt" Height="18px" Width="144px">Primary Carrier Name</asp:Label>
</td>
<td align="center" style="width: 206px" bordercolor="silver">
<asp:Label ID="Label14" runat="server" CssClass="headfield1" EnableViewState="False" Font-Names="Tahoma" Font-Size="9pt" Height="18px" Width="144px">Policy Effective Dates</asp:Label>
</td>
<td align="center" style="width: 154px" bordercolor="silver">
<asp:Label ID="Label19" runat="server" CssClass="headfield1" EnableViewState="False" Font-Names="Tahoma" Font-Size="9pt" Height="18px" Width="87px">Policy Limits</asp:Label>
</td>
<td align="center" style="width: 321px" bordercolor="silver">
<asp:Label ID="Label20" runat="server" CssClass="headfield1" EnableViewState="False" Font-Names="Tahoma" Font-Size="9pt" Height="18px" Width="164px">Policy No. Other Company</asp:Label>
</td>
</tr>
<tr>
<td align="center" style="width: 211px" colspan="" bordercolor="silver">
<asp:TextBox ID="txtPriCarierName1" runat="server" Height="12px" Width="152px" Font-Names="Tahoma" Font-Size="9pt" MaxLength="75" TabIndex="24"></asp:TextBox>
</td>
<td align="center" style="width: 206px" bordercolor="silver">
<asp:TextBox ID="txtPriPolEffecDate1" runat="server" onclick="ShowDateTimePicker();" Height="12px" Width="92px" Font-Names="Tahoma" Font-Size="9pt" TabIndex="25"></asp:TextBox>
</td>
<td align="center" style="width: 154px" bordercolor="silver">
<asp:TextBox ID="txtPriPolLimits1" runat="server" Height="12px" Width="120px" Font-Names="Tahoma" Font-Size="9pt" MaxLength="50" TabIndex="26"></asp:TextBox>
</td>
<td align="center" style="width: 321px" bordercolor="silver">
<asp:TextBox ID="txtPriClaims1" runat="server" Height="12px" Width="196px" Font-Names="Tahoma" Font-Size="9pt" MaxLength="50" TabIndex="27"></asp:TextBox>
</td>
</tr>
<tr>
<td align="center" bordercolor="silver" colspan="1" style="width: 211px; height: 22px;">
<asp:TextBox ID="txtPriCarierName2" runat="server" Height="12px" Width="152px" Font-Names="Tahoma" Font-Size="9pt" MaxLength="75" TabIndex="28"></asp:TextBox>
</td>
<td align="center" bordercolor="silver" style="width: 206px; height: 22px;">
<MaskedInput:MaskedTextBox ID="txtPriPolEffecDate2" runat="server" onclick="ShowDateTimePicker2();" CssClass="headfield1" Font-Names="Tahoma" Font-Size="9pt" Height="14px" IsDate="True" TabIndex="29" Width="92px"></MaskedInput:MaskedTextBox>
</td>
<td align="center" bordercolor="silver" style="width: 154px; height: 22px;">
<asp:TextBox ID="txtPriPolLimits2" runat="server" Height="12px" Width="120px" Font-Names="Tahoma" Font-Size="9pt" MaxLength="50" TabIndex="30"></asp:TextBox>
</td>
<td align="center" bordercolor="silver" style="width: 321px; height: 22px;">
<asp:TextBox ID="txtPriClaims2" runat="server" Height="12px" Width="196px" Font-Names="Tahoma" Font-Size="9pt" MaxLength="50" TabIndex="31"></asp:TextBox>
</td>
</tr>
<tr>
<td align="center" bordercolor="silver" colspan="1" style="width: 211px; height: 22px">
<asp:TextBox ID="txtPriCarierName3" runat="server" Height="12px" Width="152px" Font-Names="Tahoma" Font-Size="9pt" MaxLength="75" TabIndex="32"></asp:TextBox>
</td>
<td align="center" bordercolor="silver" style="width: 206px; height: 22px">
<MaskedInput:MaskedTextBox ID="txtPriPolEffecDate3" runat="server" onclick="ShowDateTimePicker3();" CssClass="headfield1" Font-Names="Tahoma" Font-Size="9pt" Height="14px" IsDate="True" TabIndex="33" Width="92px"></MaskedInput:MaskedTextBox>
</td>
<td align="center" bordercolor="silver" style="width: 154px; height: 22px">
<asp:TextBox ID="txtPriPolLimits3" runat="server" Height="12px" Width="120px" Font-Names="Tahoma" Font-Size="9pt" MaxLength="50" TabIndex="34"></asp:TextBox>
</td>
<td align="center" bordercolor="silver" style="width: 321px; height: 22px">
<asp:TextBox ID="txtPriClaims3" runat="server" Height="12px" Width="196px" Font-Names="Tahoma" Font-Size="9pt" MaxLength="50" TabIndex="35"></asp:TextBox>
</td>
</tr>
</table>
<table id="Table7" border="0" cellpadding="0" cellspacing="0" style="width: 808px;
height: 8px">
<tr>
<%--<td align="left" background="Images2/Barra3.jpg" colspan="5" style="width: 760px;
height: 3px">
<br />
</td>--%>
</tr>
<tr>
<td align="left" colspan="5" style="width: 760px">
<asp:Label ID="Label28" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma" Font-Size="9pt" Width="636px" Visible="False">3. Please provide the necessary information below with respect to your excess professional liability</asp:Label>
</td>
</tr>
<tr>
<td align="left" colspan="5" style="width: 760px">
<asp:Label ID="Label29" runat="server" CssClass="headform3" Font-Bold="False" Font-Names="Tahoma" Font-Size="9pt" Width="632px" Visible="False">insurance coverage for the last three years, including the coverage in force as of the date of this application.</asp:Label>
</td>
</tr>
<tr>
<td colspan="7" style="font-size: 5pt; width: 400px; height: 7px">
</td>
</tr>
<tr>
<td align="center" style="width: 211px" colspan="1" bordercolor="silver">
<asp:Label ID="Label31" runat="server" CssClass="headfield1" EnableViewState="False" Font-Names="Tahoma" Font-Size="9pt" Height="18px" Width="144px" Visible="False">Excess Carrier Name</asp:Label>
</td>
<td align="center" style="width: 206px" bordercolor="silver">
<asp:Label ID="Label32" runat="server" CssClass="headfield1" EnableViewState="False" Font-Names="Tahoma" Font-Size="9pt" Height="18px" Width="144px" Visible="False">Policy Effective Dates</asp:Label>
</td>
<td align="center" style="width: 154px" bordercolor="silver">
<asp:Label ID="Label33" runat="server" CssClass="headfield1" EnableViewState="False" Font-Names="Tahoma" Font-Size="9pt" Height="18px" Width="87px" Visible="False">Policy Limits</asp:Label>
</td>
<td align="center" style="width: 321px" bordercolor="silver">
<asp:Label ID="Label34" runat="server" CssClass="headfield1" EnableViewState="False" Font-Names="Tahoma" Font-Size="9pt" Height="18px" Width="164px" Visible="False">Claims-Made Form or Occurrence Form</asp:Label>
</td>
</tr>
<tr>
<td align="center" style="width: 211px" colspan="1" bordercolor="silver">
<asp:TextBox ID="txtExcCarierName1" runat="server" Height="12px" Width="152px" Font-Names="Tahoma" Font-Size="9pt" TabIndex="36" Visible="False"></asp:TextBox>
</td>
<td align="center" style="width: 206px" bordercolor="silver">
<MaskedInput:MaskedTextBox ID="txtExcPolEffecDate1" runat="server" onclick="ShowDateTimePicker4();" CssClass="headfield1" Font-Names="Tahoma" Font-Size="9pt" Height="14px" IsDate="True" TabIndex="37" Width="92px" Visible="False"></MaskedInput:MaskedTextBox>
</td>
<td align="center" style="width: 154px" bordercolor="silver">
<asp:TextBox ID="txtExcPolLimits1" runat="server" Height="12px" Width="120px" Font-Names="Tahoma" Font-Size="9pt" TabIndex="38" Visible="False"></asp:TextBox>
</td>
<td align="center" style="width: 321px" bordercolor="silver">
<asp:TextBox ID="txtExcClaims1" runat="server" Height="12px" Width="196px" Font-Names="Tahoma" Font-Size="9pt" TabIndex="39" Visible="False"></asp:TextBox>
</td>
</tr>
<tr>
<td align="center" bordercolor="silver" colspan="1" style="width: 211px; height: 22px">
<asp:TextBox ID="txtExcCarierName2" runat="server" Height="12px" Width="152px" Font-Names="Tahoma" Font-Size="9pt" TabIndex="40" Visible="False"></asp:TextBox>
</td>
<td align="center" bordercolor="silver" style="width: 206px; height: 22px">
<MaskedInput:MaskedTextBox ID="txtExcPolEffecDate2" runat="server" onclick="ShowDateTimePicker5();" CssClass="headfield1" Font-Names="Tahoma" Font-Size="9pt" Height="14px" IsDate="True" TabIndex="41" Width="92px" Visible="False"></MaskedInput:MaskedTextBox>
</td>
<td align="center" bordercolor="silver" style="width: 154px; height: 22px">
<asp:TextBox ID="txtExcPolLimits2" runat="server" Height="12px" Width="120px" Font-Names="Tahoma" Font-Size="9pt" TabIndex="42" Visible="False"></asp:TextBox>
</td>
<td align="center" bordercolor="silver" style="width: 321px; height: 22px">