function ap_validate_2106() { var form = document.ap_form_2106; var regexp_26348 = /^[a-zA-Z]+(([\'\,\.\-][a-zA-Z])?[a-zA-Z]*)*$/; var regexp_26349 = /^[a-zA-Z]+(([\'\,\.\-][a-zA-Z])?[a-zA-Z]*)*$/; var regexp_26347 = /^(([A-Za-z0-9]+_+)|([A-Za-z0-9]+\-+)|([A-Za-z0-9]+\.+)|([A-Za-z0-9]+\++))*[A-Za-z0-9]+@((\w+\-+)|(\w+\.))*\w{1,63}\.[a-zA-Z]{2,6}$/; var regexp_26359 = /^[A-Za-z0-9 -,.]{3}/; var regexp_26361 = /^\d{5}-\d{4}|\d{5}|[A-Z]\d[A-Z] \d[A-Z]\d$/; var regexp_26350 = /^((\+\d{1,3}(-| )?\(?\d\)?(-| )?\d{1,3})|(\(?\d{2,3}\)?))(-| )?(\d{3,4})(-| )?(\d{4})(( x| ext)\d{1,5}){0,1}$/; if (form.name === ""){ alert( "There was an error on this form." ); } else if (form.ap_field_26348.value === ""){ alert( "Please enter all required fields: First Name " ); } else if (!regexp_26348.test(form.ap_field_26348.value)){ form.ap_field_26348.focus(); form.ap_field_26348.select(); alert( "Please correct required field: First Name" ); } else if (form.ap_field_26349.value === ""){ alert( "Please enter all required fields: Last Name " ); } else if (!regexp_26349.test(form.ap_field_26349.value)){ form.ap_field_26349.focus(); form.ap_field_26349.select(); alert( "Please correct required field: Last Name" ); } else if (form.ap_field_26347.value === ""){ alert( "Please enter all required fields: Email Address " ); } else if (!regexp_26347.test(form.ap_field_26347.value)){ form.ap_field_26347.focus(); form.ap_field_26347.select(); alert( "Please correct required field: Email Address" ); } else if (form.ap_field_26359.value === ""){ alert( "Please enter all required fields: City " ); } else if (!regexp_26359.test(form.ap_field_26359.value)){ form.ap_field_26359.focus(); form.ap_field_26359.select(); alert( "Please correct required field: City" ); } else if (form.ap_field_26360.value === ""){ alert( "Please enter all required fields: State " ); } else if (form.ap_field_26361.value === ""){ alert( "Please enter all required fields: Zip Code " ); } else if (!regexp_26361.test(form.ap_field_26361.value)){ form.ap_field_26361.focus(); form.ap_field_26361.select(); alert( "Please correct required field: Zip Code" ); } else if (form.ap_field_26350.value === ""){ alert( "Please enter all required fields: Phone Number " ); } else if (!regexp_26350.test(form.ap_field_26350.value)){ form.ap_field_26350.focus(); form.ap_field_26350.select(); alert( "Please correct required field: Phone Number" ); } else if (form.ap_field_26375.value === ""){ alert( "Please enter all required fields: Age " ); } else { document.ap_form_2106.submit(); } } function showForm(){ var formHTML = '
First Name*
Last Name*
Spouses Name
Email Address*
Street Address
City*
State*
Zip Code*
Phone Number*
Alternate Number
Age*
Spouses Age
Health Classification
Spouses Health Classification
Do you have a policy in-force?
Have you looked into this insurance before?
Daily Benefit
Benefit Period
Elimination Period
Inflation Protection
Comments:

* Required Field

'; if(!formShown){ document.writeln(formHTML); } formShown=true; } var formShown = false; showForm();