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Pre filling in a form?

#1 apollo-articles

Dedicated Member

Group: Members
Posts: 127
Joined: 18-January 11
Reputation: 1

Posted 06 February 2012 - 04:18 PM

Hey guys,

I have a form on my website that I'd like to pre fill.

Obviously I can't pre fill the contact details section, but I'd like to get the "Insurance details" section
pre filled to the default values but still have the drop down menu available for people to change them.

Could someone tell me how to do this?

The following is my code:

<?php
include("config-tch.php");
include($header_file_name);

extract($_REQUEST);

if($submit){	
	include("life-insurance-brain.php");
}else{
// Show the form:
?>

  <script type="text/javascript">

function validate_form(form)
{

    if (form.x_C1Title.value == "") {
        alert("Please enter your title");
        return false;
    }

    if (form.x_C1Forename.value == "") {
        alert("Please enter your first name");
        return false;
    }

    if (form.x_C1Surname.value == "") {
        alert("Please enter your last name");
        return false;
    }

    if (form.x_C1DOB_day.value == "") {
        alert("Please enter the day you were born");
        return false;
    }
    if (form.x_C1DOB_month.value == "") {
        alert("Please enter the month you were born");
        return false;
    }
    if (form.x_C1DOB_year.value == "") {
        alert("Please enter the year you were born");
        return false;
    }
    if ((form.x_C1Smoker[0].checked == false) && (form.x_C1Smoker[1].checked == false)) {
        alert("Are you a smoker?");
        return false;
    }

    if (form.x_C1Email.value == "") {
        alert("Please enter your email address");
        return false;
    }

    if (form.x_C1HomeTel.value == "") {
        alert("Please enter your home telephone number");
        return false;
    }

    if ((form.x_Joint[0].checked == false) && (form.x_Joint[1].checked == false)) {
        alert("Is this a joint application?");
        return false;
    }

    //If a return journey is select, have all the return details been entered?
    if ((form.x_Joint[1].checked == true) && (form.x_C2Title.value == "" ||  form.x_C2Title.value == "" || form.x_C2Title.value == "")){
        alert("Please fill in information about your partner");
        return false;
    }

    if ((form.x_C1HouseNumber.value == "") && (form.x_C1HouseFlatName.value == "")){
        alert("Please enter your house/flat name or number");
        return false;
    }

    if (form.x_C1Street.value == "") {
        alert("Please enter your street address");
        return false;
    }
    if (form.x_C1Town.value == "") {
        alert("Please enter your town");
        return false;
    }
    if (form.x_C1County.value == "") {
        alert("Please enter your county");
        return false;
    }
    if (form.x_C1Postcode.value == "") {
        alert("Please enter your postcode");
        return false;
    }
    if (form.x_InsuranceType.value == "") {
        alert("Please enter your insurance type");
        return false;
    }
    if (form.x_CoverType.value == "") {
        alert("Please enter your cover type");
        return false;
    }
    if (form.x_CoverYears.value == "") {
        alert("Please enter the period of years");
        return false;
    }
    if (form.x_CoverAmount.value == "") {
        alert("Please enter an insurance amount");
        return false;
    }
    if (form.x_PremiumType.value == "") {
        alert("Please select a premium");
        return false;
    }
    else {

        form.submit(); 
    }
}
  
   </Script>


<form action="<?php echo $_SERVER['PHP_SELF']?>" method="post" target="_parent" name="quote" onsubmit="return validate_form (quote);">
<p>
<STYLE TYPE="text/css">
.buttonclass{ 
background-image:url(http://www.lifeinsurancequotesx.co.uk/submitbutton2.jpg); 
width:204px; 
height:39px; 
overflow: hidden; 
cursor: pointer; /* hand-shaped cursor */ 
cursor: hand; /* for IE 5.x */ 
border:0; 
}
h3 {

        color: #424242;
        font-family: "Adobe Caslon Pro", "Hoefler Text", Georgia, Garamond, Times, serif;
	letter-spacing:0.1em;
        display:inline;
	margin: 5px auto;
	text-transform: lowercase;
	line-height: 145%;
	font-size: 12pt;
	font-variant: small-caps;

}
h2 {
        color: #f3932d;
        font-family: "Trebuchet MS", "Trebuchet MS", Verdana, Lucida Sans Unicode, Lucida Grande, calibri, arial, serif;
	letter-spacing:0.1em;
	margin: 5px auto;
	line-height: 145%;
	font-size: 14pt;
	text-decoration:none;
}
h1 {
        color: #000000;
        font-family: "Trebuchet MS", "Trebuchet MS", Verdana, Lucida Sans Unicode, Lucida Grande, calibri, arial, serif;
	letter-spacing:0.1em;
	margin: 5px auto;
	line-height: 145%;
	font-size: 16pt;
	text-decoration:none;
}
<!--
TD{font-family: verdana; font-size: 14px;}
--->

</STYLE>

<input type="hidden" name="a_add" value="A">
<table border="0" width="485" cellspacing="2" cellpadding="5" table style="background-color: CFD7FD;-moz-border-radius: 15px;
border-radius: 15px;"><tr><td colspan="4" align="center"><h1>Life Insurance Quotes In 60 Seconds</h1></td></tr></font>
	<tr>
	<td colspan="4"><img src="http://www.lifeinsurancequotesx.co.uk/personal-details.png"><hr></td>
	</tr>
	<tr>
		<td width="110">Title</td>
		<td width="130"><select class="input-select" name="x_C1Title"><option value=''>-- Select--</option><option value="Miss">Miss</option><option value="Mr">Mr</option><option value="Mrs">Mrs</option><option value="Ms">Ms</option></select></td>
<td width="110"></td>
<td width="130"></td>
	</tr>
	<tr>
		<td>First Name</td>
		<td><input type="text" name="x_C1Forename" class="input-text"></td>

		<td align="right">Last Name</td>
		<td><input type="text" name="x_C1Surname" class="input-text"></td>
	</tr>
	<tr>
		<td>Date of birth</td>
		<td colspan="3"><select name="x_C1DOB_day" class="input-select" style="width:53px;">
				<option value="">Day</option>
        <option value="01" >01</option>
        <option value="02" >02</option>
        <option value="03" >03</option>
        <option value="04" >04</option>
        <option value="05" >05</option>
        <option value="06" >06</option>
        <option value="07" >07</option>
        <option value="08" >08</option>
        <option value="09" >09</option>
        <option value="10" >10</option>
        <option value="11" >11</option>
        <option value="12" >12</option>
        <option value="13" >13</option>
        <option value="14" >14</option>
        <option value="15" >15</option>
        <option value="16" >16</option>
        <option value="17" >17</option>
        <option value="18" >18</option>
        <option value="19" >19</option>
        <option value="20" >20</option>
        <option value="21" >21</option>
        <option value="22" >22</option>
        <option value="23" >23</option>
        <option value="24" >24</option>
        <option value="25" >25</option>
        <option value="26" >26</option>
        <option value="27" >27</option>
        <option value="28" >28</option>
        <option value="29" >29</option>
        <option value="30" >30</option>
        <option value="31" >31</option>
        </select>
        <select name="x_C1DOB_month" class="input-select" style="width:80px;">
							<option value="">Month</option>

        <option value="01" >Jan</option>
        <option value="02" >Feb</option>
        <option value="03" >Mar</option>
        <option value="04" >Apr</option>
        <option value="05" >May</option>
        <option value="06" >Jun</option>
        <option value="07" >Jul</option>
        <option value="08" >Aug</option>
        <option value="09" >Sep</option>
        <option value="10" >Oct</option>
        <option value="11" >Nov</option>
        <option value="12" >Dec</option>
        </select>
		<select class="input-select" name="x_C1DOB_year" style="width:55px;">
							<option value="">Year</option>

		<option value=2000 >2000</option>
				<option value=1999 >1999</option>

				<option value=1998 >1998</option>
				<option value=1997 >1997</option>
				<option value=1996 >1996</option>
				<option value=1995 >1995</option>
				<option value=1994 >1994</option>
				<option value=1993 >1993</option>

				<option value=1992 >1992</option>
				<option value=1991 >1991</option>
				<option value=1990 >1990</option>
				<option value=1989 >1989</option>
				<option value=1988 >1988</option>
				<option value=1987 >1987</option>

				<option value=1986 >1986</option>
				<option value=1985 >1985</option>
				<option value=1984 >1984</option>
				<option value=1983 >1983</option>
				<option value=1982 >1982</option>
				<option value=1981 >1981</option>

				<option value=1980 >1980</option>
				<option value=1979 >1979</option>
				<option value=1978 >1978</option>
				<option value=1977 >1977</option>
				<option value=1976 >1976</option>
				<option value=1975>1975</option>

				<option value=1974 >1974</option>
				<option value=1973 >1973</option>
				<option value=1972 >1972</option>
				<option value=1971 >1971</option>
				<option value=1970 >1970</option>
				<option value=1969 >1969</option>

				<option value=1968 >1968</option>
				<option value=1967 >1967</option>
				<option value=1966 >1966</option>
				<option value=1965 >1965</option>
				<option value=1964 >1964</option>
				<option value=1963 >1963</option>

				<option value=1962 >1962</option>
				<option value=1961 >1961</option>
				<option value=1960 >1960</option>
				<option value=1959 >1959</option>
				<option value=1958 >1958</option>
				<option value=1957 >1957</option>

				<option value=1956 >1956</option>
				<option value=1955 >1955</option>
				<option value=1954 >1954</option>
				<option value=1953 >1953</option>
				<option value=1952 >1952</option>
				<option value=1951 >1951</option>

				<option value=1950 >1950</option>
				<option value=1949 >1949</option>
				<option value=1948 >1948</option>
				<option value=1947 >1947</option>
				<option value=1946 >1946</option>
				<option value=1945 >1945</option>

				<option value=1944 >1944</option>
				<option value=1943 >1943</option>
				<option value=1942 >1942</option>
				<option value=1941 >1941</option>
				<option value=1940 >1940</option>
				<option value=1939 >1939</option>

				<option value=1938 >1938</option>
				<option value=1937 >1937</option>
				<option value=1936 >1936</option>
				<option value=1935 >1935</option>
				<option value=1934 >1934</option>
				<option value=1933 >1933</option>

				<option value=1932 >1932</option>
				<option value=1931 >1931</option>
				<option value=1930 >1930</option>
				<option value=1929 >1929</option>
				<option value=1928 >1928</option>
				<option value=1927 >1927</option>

				<option value=1926 >1926</option>
				<option value=1925 >1925</option>
				<option value=1924 >1924</option>
				<option value=1923 >1923</option>
				<option value=1922 >1922</option>
				<option value=1921 >1921</option>

				<option value=1920 >1920</option>
				<option value=1919 >1919</option>
				<option value=1918 >1918</option>
				<option value=1917 >1917</option>
				<option value=1916 >1916</option>
				<option value=1915 >1915</option>

				<option value=1914 >1914</option>
				<option value=1913 >1913</option>
				<option value=1912 >1912</option>
				<option value=1911 >1911</option>
				<option value=1910 >1910</option>
				<option value=1909 >1909</option>

				<option value=1908 >1908</option>
				<option value=1907 >1907</option>
				<option value=1906 >1906</option>
				<option value=1905 >1905</option>
				<option value=1904 >1904</option>
				<option value=1903 >1903</option>

				<option value=1902 >1902</option>
				<option value=1901 >1901</option>
				<option value=1900 >1900</option>
		</select>			
		</td>
	</tr>
	<tr>
		<td colspan="4" align="left">Do you smoke?
		<input type="radio" name="x_C1Smoker" value="No">No&nbsp;
				<input type="radio" name="x_C1Smoker" value="Yes">Yes&nbsp;</td>
	</tr>
	<tr>
	<td colspan="4"><img src="http://www.lifeinsurancequotesx.co.uk/contact-details.png"><hr></td>
	</tr>
	<tr>
		<td>Email address</td>
		<td><input type="text" name="x_C1Email" class="input-text"></td>

		<td align="right">Home phone</td>
		<td><input type="text" name="x_C1HomeTel" class="input-text"></td>
	</tr>
	<tr>
		<td>Work phone</td>
		<td><input type="text" name="x_C1WorkTel" class="input-text"></td>


		<td align="right">Mobile</td>
		<td><input type="text" name="x_C1MobilePhoneNo" class="input-text"></td>
	</tr>

	<tr>
		<td colspan="4" align="left">Is this a joint application?
		<script>
		function fieldsApp2(_obj) {
		if (_obj.value == 'Yes') {
			document.getElementById('partner_info').style.display = '';
		}
		else {
			document.getElementById('partner_info').style.display = 'none';
		}
		}
		</script>
		<input type="radio" name="x_Joint" value="No" onClick="javascript:fieldsApp2(this);">No&nbsp;
				<input type="radio" name="x_Joint" value="Yes" onClick="javascript:fieldsApp2(this);">Yes&nbsp;</td>
	</tr>
	<tbody id="partner_info" style="display:none;">
	<tr>
		<td>#2 Title</td>
		<td><select class="input-select" name="x_C2Title"><option value=''>-- Select--</option><option value="Miss">Miss</option><option value="Mr">Mr</option><option value="Mrs">Mrs</option><option value="Ms">Ms</option></select></td>

	</tr>

	<tr>

		<td align="right">#2 First Name</td>
		<td><input type="text" name="x_C2Forename" class="input-text"></td>

		<td>#2 Last Name</td>
		<td><input type="text" name="x_C2Surname" class="input-text"></td>
	</tr>
	<tr>
		<td>#2 Date of birth</td>
		<td colspan="3"><select name="x_C2DOB_day" class="input-select" style="width:50px;">
				<option value="">Day</option>
        <option value="01" >01</option>
        <option value="02" >02</option>
        <option value="03" >03</option>
        <option value="04" >04</option>
        <option value="05" >05</option>
        <option value="06" >06</option>
        <option value="07" >07</option>
        <option value="08" >08</option>
        <option value="09" >09</option>
        <option value="10" >10</option>
        <option value="11" >11</option>
        <option value="12" >12</option>
        <option value="13" >13</option>
        <option value="14" >14</option>
        <option value="15" >15</option>
        <option value="16" >16</option>
        <option value="17" >17</option>
        <option value="18" >18</option>
        <option value="19" >19</option>
        <option value="20" >20</option>
        <option value="21" >21</option>
        <option value="22" >22</option>
        <option value="23" >23</option>
        <option value="24" >24</option>
        <option value="25" >25</option>
        <option value="26" >26</option>
        <option value="27" >27</option>
        <option value="28" >28</option>
        <option value="29" >29</option>
        <option value="30" >30</option>
        <option value="31" >31</option>
        </select>
        <select name="x_C2DOB_month" class="input-select" style="width:60px;">
							<option value="">Month</option>

        <option value="01" >Jan</option>
        <option value="02" >Feb</option>
        <option value="03" >Mar</option>
        <option value="04" >Apr</option>
        <option value="05" >May</option>
        <option value="06" >Jun</option>
        <option value="07" >Jul</option>
        <option value="08" >Aug</option>
        <option value="09" >Sep</option>
        <option value="10" >Oct</option>
        <option value="11" >Nov</option>
        <option value="12" >Dec</option>
        </select>
		<select class="input-select" name="x_C2DOB_year" style="width:55px;">
							<option value="">Year</option>

		<option value=2000 >2000</option>
				<option value=1999 >1999</option>

				<option value=1998 >1998</option>
				<option value=1997 >1997</option>
				<option value=1996 >1996</option>
				<option value=1995 >1995</option>
				<option value=1994 >1994</option>
				<option value=1993 >1993</option>

				<option value=1992 >1992</option>
				<option value=1991 >1991</option>
				<option value=1990 >1990</option>
				<option value=1989 >1989</option>
				<option value=1988 >1988</option>
				<option value=1987 >1987</option>

				<option value=1986 >1986</option>
				<option value=1985 >1985</option>
				<option value=1984 >1984</option>
				<option value=1983 >1983</option>
				<option value=1982 >1982</option>
				<option value=1981 >1981</option>

				<option value=1980 >1980</option>
				<option value=1979 >1979</option>
				<option value=1978 >1978</option>
				<option value=1977 >1977</option>
				<option value=1976 >1976</option>
				<option value=1975>1975</option>

				<option value=1974 >1974</option>
				<option value=1973 >1973</option>
				<option value=1972 >1972</option>
				<option value=1971 >1971</option>
				<option value=1970 >1970</option>
				<option value=1969 >1969</option>

				<option value=1968 >1968</option>
				<option value=1967 >1967</option>
				<option value=1966 >1966</option>
				<option value=1965 >1965</option>
				<option value=1964 >1964</option>
				<option value=1963 >1963</option>

				<option value=1962 >1962</option>
				<option value=1961 >1961</option>
				<option value=1960 >1960</option>
				<option value=1959 >1959</option>
				<option value=1958 >1958</option>
				<option value=1957 >1957</option>

				<option value=1956 >1956</option>
				<option value=1955 >1955</option>
				<option value=1954 >1954</option>
				<option value=1953 >1953</option>
				<option value=1952 >1952</option>
				<option value=1951 >1951</option>

				<option value=1950 >1950</option>
				<option value=1949 >1949</option>
				<option value=1948 >1948</option>
				<option value=1947 >1947</option>
				<option value=1946 >1946</option>
				<option value=1945 >1945</option>

				<option value=1944 >1944</option>
				<option value=1943 >1943</option>
				<option value=1942 >1942</option>
				<option value=1941 >1941</option>
				<option value=1940 >1940</option>
				<option value=1939 >1939</option>

				<option value=1938 >1938</option>
				<option value=1937 >1937</option>
				<option value=1936 >1936</option>
				<option value=1935 >1935</option>
				<option value=1934 >1934</option>
				<option value=1933 >1933</option>

				<option value=1932 >1932</option>
				<option value=1931 >1931</option>
				<option value=1930 >1930</option>
				<option value=1929 >1929</option>
				<option value=1928 >1928</option>
				<option value=1927 >1927</option>

				<option value=1926 >1926</option>
				<option value=1925 >1925</option>
				<option value=1924 >1924</option>
				<option value=1923 >1923</option>
				<option value=1922 >1922</option>
				<option value=1921 >1921</option>

				<option value=1920 >1920</option>
				<option value=1919 >1919</option>
				<option value=1918 >1918</option>
				<option value=1917 >1917</option>
				<option value=1916 >1916</option>
				<option value=1915 >1915</option>

				<option value=1914 >1914</option>
				<option value=1913 >1913</option>
				<option value=1912 >1912</option>
				<option value=1911 >1911</option>
				<option value=1910 >1910</option>
				<option value=1909 >1909</option>

				<option value=1908 >1908</option>
				<option value=1907 >1907</option>
				<option value=1906 >1906</option>
				<option value=1905 >1905</option>
				<option value=1904 >1904</option>
				<option value=1903 >1903</option>

				<option value=1902 >1902</option>
				<option value=1901 >1901</option>
				<option value=1900 >1900</option>
		</select>			
		</td>
	</tr>
	<tr>
		<td colspan="2" align="right">#2 Do you smoke?</td>
		<td colspan="2" align="left"><input type="radio" name="x_C2Smoker" value="No">No&nbsp;
				<input type="radio" name="x_C2Smoker" value="Yes">Yes&nbsp;</td>
	</tr>
	</tbody>
	<tr>
		<td>House Number</td>
		<td><input type="text" name="x_C1HouseNumber" class="input-text"></td>

		<td align="right">House Name</td>
		<td><input type="text" name="x_C1HouseFlatName" class="input-text" value=""></td>
	</tr>

	<tr>
		<td>Street</td>
		<td><input type="text" name="x_C1Street" class="input-text"></td>

		<td align="right">Area</td>
		<td><input type="text" name="x_C1Area" class="input-text"></td>
	</tr>
	<tr>

	<tr>
		<td>Town</td>
		<td><input type="text" name="x_C1Town" class="input-text"></td>

		<td align="right">County</td>
		<td><input type="text" name="x_C1County" class="input-text"></td>
	</tr>

	<tr>
		<td>Postcode</td>
		<td><input type="text" name="x_C1Postcode" class="input-text"></td>
	</tr>

	<td colspan="4"><img src="http://www.lifeinsurancequotesx.co.uk/insurance-details.png"><hr></td>
	</tr>
	<tr>
		<td>Insure Type</td>
		<td><select class="input-select" name="x_InsuranceType">
				<option value=''>-- Select--</option>
				<option value="Life Insurance">Life Insurance only</option>
				<option value="Life Insurance and Critical Illness">Life insurance + Critical illness</option>
			</select>&nbsp;&nbsp;<img src="http://www.lifeinsurancequotesx.co.uk/question-mark-3.png" alt="question mark" class="alignright" title="Critical illness pays out if the policy holder is diagnosed with a critical illness that's listed within the policy.&nbsp;

Don't know?&nbsp;
We only use this information to help give you an appropriate quote, your choice now isn't permanent."/></td>

<td align="right">Cover Type</td>
		<td><nobr><select class="input-select" name="x_CoverType">
				<option value=''>-- Select--</option>
				<option value="Level Cover">Level Cover</option>
				<option value="Decreasing Cover">Decreasing Cover</option>
			</select>&nbsp;&nbsp;<img src="http://www.lifeinsurancequotesx.co.uk/question-mark-3.png" alt="question mark" class="alignright" title="Level Term insurance is the classic life insurance paying out if the insured dies within the relevant term.

Deacreasing Cover charges less as your policy goes on since it's typically designed so if you die your remaining debt owed on mortages are paid off.&nbsp;

Don't know? &nbsp;
This option is only designed to be a guide for your quote, you can easily change your choice later."/></nobr>
			</td>

	</tr>

	<tr>
		<td>Time Period?</td>
		<td><nobr><select class="input-select" name="x_CoverYears">
				<option value=''>-- Select--</option>		
          <option value="1 year">1 year</option>
          <option value="2 years">2 years</option>
          <option value="3 years">3 years</option>
          <option value="4 years">4 years</option>
          <option value="5 years">5 years</option>
          <option value="6 years">6 years</option>
          <option value="7 years">7 years</option>
          <option value="8 years">8 years</option>
          <option value="9 years">9 years</option>
          <option value="10 years">10 years</option>
          <option value="11 years">11 years</option>
          <option value="12 years">12 years</option>
          <option value="13 years">13 years</option>
          <option value="14 years">14 years</option>
          <option value="15 years">15 years</option>
          <option value="16 years">16 years</option>
          <option value="17 years">17 years</option>
          <option value="18 years">18 years</option>
          <option value="19 years">19 years</option>
          <option value="20 years">20 years</option>
          <option value="21 years">21 years</option>
          <option value="22 years">22 years</option>
          <option value="23 years">23 years</option>
          <option value="24 years">24 years</option>
          <option value="25 years">25 years</option>
          <option value="26 years">26 years</option>
          <option value="27 years">27 years</option>
          <option value="28 years">28 years</option>
          <option value="29 years">29 years</option>
          <option value="30 years">30 years</option>
          <option value="31 years">31 years</option>
          <option value="32 years">32 years</option>
          <option value="33 years">33 years</option>
          <option value="34 years">34 years</option>
          <option value="35 years">35 years</option>
          <option value="36 years">36 years</option>
          <option value="37 years">37 years</option>
          <option value="38 years">38 years</option>
          <option value="39 years">39 years</option>
          <option value="40 years">40 years</option>
          <option value="41 years">41 years</option>
          <option value="42 years">42 years</option>
          <option value="43 years">43 years</option>
          <option value="44 years">44 years</option>
          <option value="45 years">45 years</option>
          <option value="46 years">46 years</option>
          <option value="47 years">47 years</option>
          <option value="48 years">48 years</option>
          <option value="49 years">49 years</option>
          <option value="50 years">50 years</option>
        </select>&nbsp;&nbsp;<img src="http://www.lifeinsurancequotesx.co.uk/question-mark-3.png" alt="question mark" class="alignright" title="Select the length that you require the cover to run for.&nbsp;
        
Don't know?&nbsp;
We only use this information to help give you an appropriate quote, your choice now isn't permanent."/></nobr>
			</td>

		<td align="right">Amount</td>
		<td><nobr><select class="input-select" name="x_CoverAmount">
			<option value=''>-- Select--</option>
				<option value="20000">&pound;20,000</option>
				<option value="25000">&pound;25,000</option>
				<option value="30000">&pound;30,000</option>
				<option value="35000">&pound;35,000</option>
				<option value="40000">&pound;40,000</option>
				<option value="45000">&pound;45,000</option>
				<option value="50000">&pound;50,000</option>
				<option value="55000">&pound;55,000</option>
				<option value="60000">&pound;60,000</option>
				<option value="65000">&pound;65,000</option>
				<option value="70000">&pound;70,000</option>
				<option value="75000">&pound;75,000</option>
				<option value="80000">&pound;80,000</option>
				<option value="85000">&pound;85,000</option>
				<option value="90000">&pound;90,000</option>
				<option value="95000">&pound;95,000</option>
				<option value="100000">&pound;100,000</option>
				<option value="105000">&pound;105,000</option>
				<option value="110000">&pound;110,000</option>
				<option value="115000">&pound;115,000</option>
				<option value="120000">&pound;120,000</option>
				<option value="125000">&pound;125,000</option>
				<option value="130000">&pound;130,000</option>
				<option value="135000">&pound;135,000</option>
				<option value="140000">&pound;140,000</option>
				<option value="145000">&pound;145,000</option>
				<option value="150000">&pound;150,000</option>
				<option value="155000">&pound;155,000</option>
				<option value="160000">&pound;160,000</option>
				<option value="165000">&pound;165,000</option>
				<option value="170000">&pound;170,000</option>
				<option value="175000">&pound;175,000</option>
				<option value="180000">&pound;180,000</option>
				<option value="185000">&pound;185,000</option>
				<option value="190000">&pound;190,000</option>
				<option value="195000">&pound;195,000</option>
				<option value="200000">&pound;200,000</option>
				<option value="205000">&pound;205,000</option>
				<option value="210000">&pound;210,000</option>
				<option value="215000">&pound;215,000</option>
				<option value="220000">&pound;220,000</option>
				<option value="225000">&pound;225,000</option>
				<option value="230000">&pound;230,000</option>
				<option value="235000">&pound;235,000</option>
				<option value="240000">&pound;240,000</option>
				<option value="245000">&pound;245,000</option>
				<option value="250000">&pound;250,000</option>
				<option value="255000">&pound;255,000</option>
				<option value="260000">&pound;260,000</option>
				<option value="265000">&pound;265,000</option>
				<option value="270000">&pound;270,000</option>
				<option value="275000">&pound;275,000</option>
				<option value="280000">&pound;280,000</option>
				<option value="285000">&pound;285,000</option>
				<option value="290000">&pound;290,000</option>
				<option value="295000">&pound;295,000</option>
				<option value="300000">&pound;300,000</option>
				<option value="325000">&pound;325,000</option>
				<option value="350000">&pound;350,000</option>
				<option value="375000">&pound;375,000</option>
				<option value="400000">&pound;400,000</option>
				<option value="425000">&pound;425,000</option>
				<option value="450000">&pound;450,000</option>
				<option value="475000">&pound;475,000</option>
				<option value="500000">&pound;500,000</option>
				<option value="550000">&pound;550,000</option>
				<option value="600000">&pound;600,000</option>
				<option value="650000">&pound;650,000</option>
				<option value="700000">&pound;700,000</option>
				<option value="750000">&pound;750,000</option>
				<option value="800000">&pound;800,000</option>
				<option value="850000">&pound;850,000</option>
				<option value="900000">&pound;900,000</option>
				<option value="950000">&pound;950,000</option>
				<option value="1000000">&pound;1,000,000</option>
				<option value="1100000">&pound;1,100,000</option>
				<option value="1200000">&pound;1,200,000</option>
				<option value="1300000">&pound;1,300,000</option>
				<option value="1400000">&pound;1,400,000</option>
				<option value="1500000">&pound;1,500,000</option>	
			</select>&nbsp;&nbsp;<img src="http://www.lifeinsurancequotesx.co.uk/question-mark-3.png" alt="question mark" class="alignright" title="Life insurance is primarily used to replace income or repay debts in the event of the policy holders death. &nbsp;
			
The figures here represent a lump sum payout in the event of the policy holders death. &nbsp;

Consider your dependants and/or debts.&nbsp;

Don't know?&nbsp;
We only use this information to help give you an appropriate quote, your choice now isn't permanent."/></nobr>
			</td>



	</tr>

	<tr>
		<td>Premium Type</td>
		<td><select class="input-select" name="x_PremiumType">
				<option value=''>-- Select--</option>
				<option value="Guaranteed Premiums">Guaranteed Premiums</option>
				<option value="Reviewable Premiums">Reviewable Premiums</option>
			</select>&nbsp;&nbsp;<img src="http://www.lifeinsurancequotesx.co.uk/question-mark-3.png" alt="question mark" class="alignright" title="Guaranteed premiums ensure your insurance company will never increase your premium for the duration of the policy term.&nbsp;

Reviewable premiums allow your insurance company to review your policy cost.&nbsp;

Don't know?&nbsp;
We only use this information to help give you an appropriate quote, your choice now isn't permanent. "/>
			</td>
	</tr>
</table>
<p>
<input type="hidden" name="IPAddress" value="<?php echo $_SERVER['REMOTE_ADDR'];?>">
<input type="hidden" name="keyword" value="<?php echo $keyword;?>">
<input name="submit" class="buttonclass" value=" " type="submit"/><br><br> 
<small><i>By clicking "Submit" you agree to be contacted by telephone
 or email by an FSA Authorised Advisor and confirm that you
 have read and agreed to our <a href="http://www.lifeinsurancequotesx.co.uk/terms-conditions/index.php?keyword=<?php echo ($_GET['keyword']); ?>"target="_parent">Terms & Conditions</a> and <a href="http://www.lifeinsurancequotesx.co.uk/privacy-policy/index.php?keyword=<?php echo ($_GET['keyword']); ?>"target="_parent">Privacy Policy</a>
 <br>
 <br>
 *The majority of life insurance policies will require no medical examination,
 however there maybe rare cases when a medical examination maybe required.
   <br><br>
<img src="http://www.lifeinsurancequotesx.co.uk/data-protection-logo.png" ALIGN="top"/>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;<img src="http://www.lifeinsurancequotesx.co.uk/ico-logo.png" ALIGN="top"/>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;Proudly registered with the ICO. </i></small>
</form>
<?php
}
include($footer_file_name);
?>

Thanks,

Sam

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#2 brightonmike

Web Guru

Group: Members
Posts: 2,996
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Experience:Intermediate
Area of Expertise:Web Designer

Posted 06 February 2012 - 04:31 PM

Just fill in the fields "value" attribute, then use jQuery val to set the values on the fields onchange.

1

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#3 Renaissance-Design

Available for custom WordPress work

Group: Moderators
Posts: 3,595
Joined: 12-August 10
Reputation: 559
Gender:Male
Location:South Wales
Experience:Web Guru
Area of Expertise:Designer/Coder

Posted 06 February 2012 - 04:43 PM

In the name of all that's holy:

<?php for $y = 2000; $y > 1899; $y--): ?>
  <option value="<?php echo $y; ?>"><?php echo $y; ?></option>
<?php endfor; ?>

Edit. In fact, this would be even better:

<?php 
$year = date('Y'); 
for $y = ($year - 12); $y > ($year - 113); $y--): ?>
  <option value="<?php echo $y; ?>"><?php echo $y; ?></option>
<?php endfor; ?>

This post has been edited by Renaissance-Design: 06 February 2012 - 05:03 PM

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#4 apollo-articles

Dedicated Member

Group: Members
Posts: 127
Joined: 18-January 11
Reputation: 1

Posted 10 February 2012 - 02:50 PM

Thanks all sorted!

Sam

0

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