From: "Saved by Windows Internet Explorer 8" Subject: Individual & Family Plans Date: Wed, 2 Feb 2011 07:33:19 -0700 MIME-Version: 1.0 Content-Type: multipart/related; type="text/html"; boundary="----=_NextPart_000_0000_01CBC2AB.76E275A0" X-MimeOLE: Produced By Microsoft MimeOLE V6.1.7600.16543 This is a multi-part message in MIME format. ------=_NextPart_000_0000_01CBC2AB.76E275A0 Content-Type: text/html; charset="iso-8859-1" Content-Transfer-Encoding: quoted-printable Content-Location: https://www.deltadentalaz.com/secured/eforms/setup1.asp Individual & = Family Plans
Delta Dental of = Arizona
Enrollment

Registration Form = -- Part 1=20 of 5
*Required
 P= ress=20 button below to continue 
QUALIFYING=20 EVENT
New=20 Enrollment

BROKERS
  141=20 =  [565cbed5-abbf-4f31-82c0-984d01504c66]=20

DENTAL PLAN=20 SELECTION Plan Details
Choose your monthly plan* Green  Blue  Purple  Orange  Yellow 
Individual Only $44.32  $41.72  $30.53  $25.20  $18.71 
Individual + 1 = Dependent $81.99  $77.18  $56.48  $46.62  $34.61 
Individual + 2 or More=20 Dependents $125.43  $118.07  $86.40  $71.32  $60.81 

Individual coverage only covers you=20
Individual + 1 dependent coverage includes you and only = one=20 qualified dependent
Individual + 2 or more dependents = coverage=20 includes you and multiple qualified dependents=20 =


=
VISION PLAN=20 SELECTION
Choose your monthly plan Gold Vision Plan 
DeltaVision = Individual $4.73 
DeltaVision + 1 = Dependent $9.46 
DeltaVision + 2 or More = Dependents $20.27 
Would you like to add = vision=20 coverage to your dental plan? YesNo
Must be=20 enrolled in a DDAZ Individual Plan to be eligible for = DeltaVision.=20 Individual Dental coverage will result in Individual Vision=20 coverage; likewise, Family Dental coverage will result in = Family=20 Vision = coverage.

<= !-- Membership Information -->
MEMBERSHIP INFORMATION
Applicant First = Name*
Applicant Last = Name*
Middle Initial
Social Security = Number*   =20
Marital Status*
Gender*
Date of Birth*=20 (mm/dd/yyyy) / / = 19931991198919871985198319811979197719751973197119691967196519631961195919571955195319511949194719451943194119391937193519331931192919271925192319211919191719151913 =20
Only AZ=20 residents 18 years of age or older qualify to be Subscribers = on the=20 Individual Plan.
Home = Address(Mailing)*
City* (AZ = Residents=20 Only) , AZ
Zip Code*  
Home Telephone*  =20
Email Address*  =20

=20

=A9 = Copyright 2011=20 Delta Dental of Arizona
All Rights Reserved

------=_NextPart_000_0000_01CBC2AB.76E275A0 Content-Type: image/png Content-Transfer-Encoding: base64 Content-Location: https://www.deltadentalaz.com/images/deltadentalblackbox.png iVBORw0KGgoAAAANSUhEUgAAAKQAAAApCAMAAACMRXJ1AAAAGXRFWHRTb2Z0d2FyZQBBZG9iZSBJ bWFnZVJlYWR5ccllPAAAAqxQTFRFQUFB1tbWycnJKSkpKioq+/v72NjYcHBwBwcHAQEB/f392tra FRUVLCwsWVlZREREQkJCzMzMvr6+sbGxhYWFR0dHLS0ty8vL0NDQ19fXysrKGRkZtbW1CgoKBQUF xcXF1dXVRUVFEhIS2dnZ29vbi4uL8PDwqKio7+/v/v7+RkZG+vr64ODgbGxsBAQEMjIyNTU1u7u7 tLS0urq6vb29WFhYsrKyzc3N9vb29PT0ISEhz8/PampqdnZ2iIiIKysrubm5KCgoZGRkVFRUq6ur T09PLy8vLi4u5eXlVlZWIiIia2trFhYWHR0dMTExDQ0NAgICeHh4AwMDioqK39/fh4eHS0tLTU1N JiYmxsbGenp6np6e+fn5b29vMzMzf39/ZWVlv7+/hoaGd3d35+fnGBgY09PTrKysFBQUCAgIICAg SEhINDQ0xMTEJSUlZmZmPj4+YGBgNjY2HBwcOjo6Dg4OIyMjCwsLDw8PWlpakpKS+Pj4sLCwCQkJ SUlJlpaW8vLy5ubmXl5ep6enVVVVqamp3NzchISEUFBQHx8f/Pz8XV1dbW1tuLi4fn5+wcHB8/Pz 4uLiQEBAiYmJbm5us7OzcXFxEBAQwMDAg4ODOzs7Q0NDjIyMkJCQmZmZGhoaODg4t7e3Pz8/nJyc zs7OyMjI3t7eJCQkdHR0Tk5Ow8PD1NTUOTk5n5+faGhoDAwMPT09ERER0dHRfX19x8fH6OjoTExM mpqa9/f3V1dXPDw8MDAwZ2dn7e3tcnJyjo6OgYGBo6Oj8fHx4eHhra2tYWFhFxcXUlJSY2Njrq6u mJiYc3NzW1tb7OzsU1NT7u7u6urqExMTfHx80tLSBgYGpKSkkZGRpaWlSkpKtra2jY2NaWlp9fX1 Hh4eNzc3UVFRlZWV3d3d////AAAA7mxzBQAABMRJREFUeNrsl/dfU0kQwEMSYioJCQlJICBNegdB QOm9gzQVREV6kyZIsdfz9M6ze9az936999573/lHbua9JHI/XfzpuPu8/WFmdnZ23pfZ2QVE8B8Y IgFSgBQgBUgB8n8MaVvv941irkPu7vO/un9srlfyScbYc3O9JzWbGFvU+28wKVyEXNtSIDVjKQ1O j1zzcstQwWkuyVimBIepTG2SmALhiIZmkswSgO5Mab89PjC2oDdO2sltzZZSgGb8ljpQjfMuVH7l /C6TGmqkUo0PpS3JlGbLAaTFxhhXIH3i0z3vriliLPIDhyvtQkq62XN/aPQ4yN+xinF4Rw94i709 oMGbZmJrKHx51Cq+L+HjJ857pput+uW5ACVNXIB3xBv6JP0TAB6ojofwuzxbwYhLeTUAMaFWcVMa 2F5ZebjcFcgNWMSospUon/ZxnD7jR5ihXLGZNz+qQ7EYBuwrUbCN1DI+frHDW1uVbTffpTZX3QHK uy3L7vSCb0m1APgtRa0B+UR0q9oFyMFFGJ4M79GuZ+0+qbs9K7shVzGm1BuycrxwNg9u2v1F0EEq xY+Ln+cIZxm7Ixl7KmFhom4hTddANcr8VfbVndOfkqpDyPmMuUux1Uz9in+GtPnjrlXYHRmoFxQ+ gnz1KwN63G9/jX1wsz5XHcJBxi1JQN32eunwAvpcZJwT0v9jT6rdSCqeyGf5u0YTab3NJxplbnLt RfpK3W+/c6yyaSeka7eb8q84h0ZlClofVjkhl0K3FT3V+Gll0pQhcAkHqYAJ1GIFNOOPhJy1ziTf wfUHjIW3onNTwqEbEM/xnKRKegD8iOowAJY3KpWFix4Pcphabjtnvh+OOFon5Ns2eIY6wMqfVOFO FM24Voz6AtSk42swxZhF7oDcCHCVDvhzPl6OfajEd82Th6T6HwSft7CNzzO2AWIIUuIaZNcpuh4V /ESPdp/aAXkRYs7SXcGvhN9PjFdTJTNwzYMqCXEIkLMFOUYckCfhNLa1MgcrmapPCgU87kkDD4yQ vtw5vIanVo4XNViuIMg01yDLXsDND/Yd88JRzR2QxAH5RfISlO4v3WVsz8H63EDqSUPpsoZkDhKL vKJxbRhjPzkgzxaHogy+jj3ZVrwr34aQ7rqm2ZB7oZ0xM+Sj2QAIqQxpvjfiAmQlbQ5nj0ZepQNS SbeedXQFoen7Zt4WLz7A/0US0+g1x3AtdsQOOfkLLV/+lW739u87zhzCmfSE+yzIgWwlNXEn/mi+ Vdf4dKtd6UlTGJs9ii797Z1kYikU8dap1XbIT0hcQREC8DOq6Fnv5OTWW41204O68DZMkY1vehKq UjoMEQe8J3b+Y0DCMZmbc1gsGbxz7FqwSiUzH/2jEORZXEDQ5b1BpGXL62Uo9gVZ3AYBGtstMvq7 ZB2Gq9xS4u/Z4FK7hYvTbtyhCu6FWHOwascVgOeD3GQ5eRZZ3yhGy9z+XLeVS6sqdQmyMkDkHDpd De9cL5ox9pyIo19AVWe0tBRRkhZBOqCgLECkrRgK0B3Ae604rtMO4mM8PNNjNIoqxmnrAR0X1xn7 sGfmDsDQD8aHmKcwQqTtP6fT0h0dDRBFmGK5tMZu4d8HAVKAFCAFSAFSgBQgBUhu/CXAAJqSDjTE RwI7AAAAAElFTkSuQmCC ------=_NextPart_000_0000_01CBC2AB.76E275A0 Content-Type: image/gif Content-Transfer-Encoding: base64 Content-Location: https://www.deltadentalaz.com/secured/eforms/images/down-arrow.gif R0lGODlhCQAOAPcAAP//////zP//mf//Zv//M///AP/M///MzP/Mmf/MZv/MM//MAP+Z//+ZzP+Z mf+ZZv+ZM/+ZAP9m//9mzP9mmf9mZv9mM/9mAP8z//8zzP8zmf8zZv8zM/8zAP8A//8AzP8Amf8A Zv8AM/8AAMz//8z/zMz/mcz/Zsz/M8z/AMzM/8zMzMzMmczMZszMM8zMAMyZ/8yZzMyZmcyZZsyZ M8yZAMxm/8xmzMxmmcxmZsxmM8xmAMwz/8wzzMwzmcwzZswzM8wzAMwA/8wAzMwAmcwAZswAM8wA AJn//5n/zJn/mZn/Zpn/M5n/AJnM/5nMzJnMmZnMZpnMM5nMAJmZ/5mZzJmZmZmZZpmZM5mZAJlm /5lmzJlmmZlmZplmM5lmAJkz/5kzzJkzmZkzZpkzM5kzAJkA/5kAzJkAmZkAZpkAM5kAAGb//2b/ zGb/mWb/Zmb/M2b/AGbM/2bMzGbMmWbMZmbMM2bMAGaZ/2aZzGaZmWaZZmaZM2aZAGZm/2ZmzGZm mWZmZmZmM2ZmAGYz/2YzzGYzmWYzZmYzM2YzAGYA/2YAzGYAmWYAZmYAM2YAADP//zP/zDP/mTP/ ZjP/MzP/ADPM/zPMzDPMmTPMZjPMMzPMADOZ/zOZzDOZmTOZZjOZMzOZADNm/zNmzDNmmTNmZjNm MzNmADMz/zMzzDMzmTMzZjMzMzMzADMA/zMAzDMAmTMAZjMAMzMAAAD//wD/zAD/mQD/ZgD/MwD/ AADM/wDMzADMmQDMZgDMMwDMAACZ/wCZzACZmQCZZgCZMwCZAABm/wBmzABmmQBmZgBmMwBmAAAz /wAzzAAzmQAzZgAzMwAzAAAA/wAAzAAAmQAAZgAAMwAAAP8ADf///wAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAA AAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAAACH5BAEAANkALAAAAAAJAA4A AAgvALNlwzawoECDBxMSxEbw4MKEAhkObBhxIkWLCC1KdMhwY8ePEkFu1HgRI8SMAQEAOw== ------=_NextPart_000_0000_01CBC2AB.76E275A0 Content-Type: image/gif Content-Transfer-Encoding: base64 Content-Location: https://www.deltadentalaz.com/secured/eforms/images/quesmark2.gif R0lGODlhDAAMALMAAPz09PjU2fO1vuEYNPro6uQxSelXavGap+2AjuVCV+AGI+tuf/z///3///7/ /////yH5BAAAAAAALAAAAAAMAAwAAARe8D2AlFUmMEnKOAEheMKUFASjOswyBIdCOIiHME1hJEbT HAKDItAQDBQHycQwIDwIx+TDkUjMHIBBYaEEOiTGmNNhQHypBkAhAcACphVip3AgAAQJhcDxJbgG gBlTEQA7 ------=_NextPart_000_0000_01CBC2AB.76E275A0 Content-Type: text/css; charset="iso-8859-1" Content-Transfer-Encoding: quoted-printable Content-Location: https://www.deltadentalaz.com/secured/eforms/inc_Layout.css A { COLOR: #333366 } A:hover { COLOR: #993333 } P { FONT-FAMILY: Arial, Helvetica, sans-serif; FONT-SIZE: 12px } TD { FONT-FAMILY: Arial, Helvetica, sans-serif; FONT-SIZE: 12px } SELECT { FONT-FAMILY: Arial, Helvetica, sans-serif; FONT-SIZE: 12px } INPUT { FONT-FAMILY: Arial, Helvetica, sans-serif; FONT-SIZE: 12px } .Subheads { LINE-HEIGHT: 110%; FONT-FAMILY: "Times New Roman", Times, serif; COLOR: = #6a5b97; FONT-SIZE: 20px } .Subheads_O { FONT-FAMILY: "Times New Roman", Times, serif; COLOR: #fd923c; = FONT-SIZE: 20px } .Subheads_G { FONT-FAMILY: "Times New Roman", Times, serif; COLOR: #66bb49; = FONT-SIZE: 20px } .Subheads_P { FONT-FAMILY: "Times New Roman", Times, serif; COLOR: #fa8d9e; = FONT-SIZE: 20px } .Subheads_A { FONT-FAMILY: "Times New Roman", Times, serif; COLOR: #d4d06d; = FONT-SIZE: 20px } .Subheads_B { FONT-FAMILY: "Times New Roman", Times, serif; COLOR: #99ccdc; = FONT-SIZE: 20px } .bodyContent { LINE-HEIGHT: 125%; FONT-FAMILY: Arial, Helvetica, sans-serif; COLOR: = #333333; FONT-SIZE: 12px } A.bodyContent { COLOR: #993333 } .redText { COLOR: #993333 } .location { FONT-FAMILY: Arial, Helvetica, sans-serif; FONT-SIZE: 10px } A.location { COLOR: #000000; TEXT-DECORATION: underline } A.locationInd:hover { COLOR: #993333; TEXT-DECORATION: underline } .error { PADDING-BOTTOM: 15px; FONT-FAMILY: Arial, Helvetica, sans-serif; COLOR: = #ff0000; FONT-SIZE: 12px; FONT-WEIGHT: bold } .tablebox { BORDER-BOTTOM: #000000 1px solid; BORDER-LEFT: #000000 1px solid; = WIDTH: 100%; BORDER-TOP: #000000 1px solid; BORDER-RIGHT: #000000 1px = solid } .dash { FONT-STYLE: normal; FONT-FAMILY: Times New Roman, Times, serif; COLOR: = #993333; FONT-SIZE: 18px; FONT-WEIGHT: normal } .purple2BarHead { BACKGROUND-COLOR: #dad6e5; PADDING-LEFT: 3px; DISPLAY: block; = FONT-FAMILY: Arial, Helvetica, sans-serif; COLOR: #000000; FONT-SIZE: = 12px; FONT-WEIGHT: bold } .greenBarHead { BACKGROUND-COLOR: #66bb49; PADDING-LEFT: 3px; DISPLAY: block; = FONT-FAMILY: Arial, Helvetica, sans-serif; COLOR: #ffffff; FONT-SIZE: = 12px; FONT-WEIGHT: bold } .green2BarHead { BACKGROUND-COLOR: #d9eed1; PADDING-LEFT: 3px; DISPLAY: block; = FONT-FAMILY: Arial, Helvetica, sans-serif; COLOR: #000000; FONT-SIZE: = 12px; FONT-WEIGHT: bold } .blueBarHead { BACKGROUND-COLOR: #99ccdc; PADDING-LEFT: 3px; DISPLAY: block; = FONT-FAMILY: Arial, Helvetica, sans-serif; COLOR: #000000; FONT-SIZE: = 12px; FONT-WEIGHT: bold } .blue2BarHead { BACKGROUND-COLOR: #e5f2f6; PADDING-LEFT: 3px; DISPLAY: block; = FONT-FAMILY: Arial, Helvetica, sans-serif; COLOR: #000000; FONT-SIZE: = 12px; FONT-WEIGHT: bold } .orangeBarHead { BACKGROUND-COLOR: #fec89d; PADDING-LEFT: 3px; DISPLAY: block; = FONT-FAMILY: Arial, Helvetica, sans-serif; COLOR: #ffffff; FONT-SIZE: = 12px; FONT-WEIGHT: bold } .orange2BarHead { BACKGROUND-COLOR: #fee4ce; PADDING-LEFT: 3px; DISPLAY: block; = FONT-FAMILY: Arial, Helvetica, sans-serif; COLOR: #000000; FONT-SIZE: = 12px; FONT-WEIGHT: bold } .almondBarHead { BACKGROUND-COLOR: #e9e7b6; PADDING-LEFT: 3px; DISPLAY: block; = FONT-FAMILY: Arial, Helvetica, sans-serif; COLOR: #000000; FONT-SIZE: = 12px; FONT-WEIGHT: bold } .almond2BarHead { BACKGROUND-COLOR: #cccccc; PADDING-LEFT: 3px; DISPLAY: block; = FONT-FAMILY: Arial, Helvetica, sans-serif; COLOR: #000000; FONT-SIZE: = 12px; FONT-WEIGHT: bold } .barBodyOrange { BACKGROUND-COLOR: #fee4ce; FONT-FAMILY: Arial, Helvetica, sans-serif; = COLOR: #333333; FONT-SIZE: 12px } .barBodyBlue { BACKGROUND-COLOR: #e5f2f6; FONT-FAMILY: Arial, Helvetica, sans-serif; = COLOR: #333333; FONT-SIZE: 12px } .barBodyGreen { BACKGROUND-COLOR: #d9eed1; FONT-FAMILY: Arial, Helvetica, sans-serif; = COLOR: #333333; FONT-SIZE: 12px } .barBodyAlmond { BACKGROUND-COLOR: #e9e7b6; FONT-FAMILY: Arial, Helvetica, sans-serif; = COLOR: #333333; FONT-SIZE: 12px } .barBodyPink { BACKGROUND-COLOR: #ffc0cb; FONT-FAMILY: Arial, Helvetica, sans-serif; = COLOR: #333333; FONT-SIZE: 12px } .barBodyPurple { BACKGROUND-COLOR: #dad6e5; FONT-FAMILY: Arial, Helvetica, sans-serif; = COLOR: #333333; FONT-SIZE: 12px } .barBodySilver { BACKGROUND-COLOR: #dddddd; FONT-FAMILY: Arial, Helvetica, sans-serif; = COLOR: #333333; FONT-SIZE: 12px } .barBodyGold { BACKGROUND-COLOR: #e9e7b6; FONT-FAMILY: Arial, Helvetica, sans-serif; = COLOR: #333333; FONT-SIZE: 12px } .barBodyYellow { BACKGROUND-COLOR: #fcf3b2; FONT-FAMILY: Arial, Helvetica, sans-serif; = COLOR: #333333; FONT-SIZE: 12px } .bodyIndent { PADDING-LEFT: 15px; FONT-FAMILY: Arial, Helvetica, sans-serif; COLOR: = #333333; FONT-SIZE: 12px; FONT-WEIGHT: bold } .header1 { FONT: bold 15pt Arial, Helvetica; COLOR: #000000 } .header2 { FONT: bold 12pt Arial, Helvetica; COLOR: #000000 } .header3 { FONT: bold 10pt Arial, Helvetica; COLOR: #000000 } .breakhere { PAGE-BREAK-AFTER: always } .smallText { FONT-FAMILY: Arial, Helvetica, sans-serif; COLOR: #666666; FONT-SIZE: = 10px } .smallTextRed { FONT-FAMILY: Arial, Helvetica, sans-serif; COLOR: red; FONT-SIZE: 10px } .smallFormText { FONT-FAMILY: Arial, Helvetica, sans-serif; COLOR: #34282c; FONT-SIZE: = 9pt; FONT-WEIGHT: bold } .boldTextRed { FONT-FAMILY: Arial, Helvetica, sans-serif; COLOR: red; FONT-SIZE: 14px; = FONT-WEIGHT: bold } .bggray { BACKGROUND-COLOR: #cccccc } ------=_NextPart_000_0000_01CBC2AB.76E275A0 Content-Type: application/octet-stream Content-Transfer-Encoding: quoted-printable Content-Location: https://www.deltadentalaz.com/secured/eforms/inc_Setup1.js //Individual Plan codes function setupA(){ //Qualifying Event // DENTAL GROUP NUMBER if (document.calform.qualifyEvent.value =3D=3D "220") {=20 if (!ValField(document.calform.azStateID,'an',18,21,'y','Dental Group = Number','Dental Group Number ')) return false; var str=3Ddocument.calform.azStateID.value; var locstr=3Dstr.indexOf('7'); if (locstr !=3D 1) {window.alert('The group number entered is invalid '+str+'.'); document.calform.azStateID.focus(); return false;} =09 } if ((document.calform.qualifyEvent.value !=3D "7") && = (document.calform.qualifyEvent.value !=3D "220") && = (document.calform.qualifyEvent.value !=3D "264")) {=20 if (valButtonOne(document.calform.qualifyEvent) =3D=3D false) { if (document.calform.whatLanguage.value =3D=3D"1")=20 {window.alert("Seleccione una razon para este cambio en el cuadro = de clasificaci=F3n de evento."); } else {window.alert("Select a reason for this change in the Qualifying = Event box."); } document.calform.qualifyEvent[0].focus();=20 return false;} for (var i=3D0; i < document.calform.qualifyEvent.length; i++) { if (document.calform.qualifyEvent[i].checked) { var rad_val =3D document.calform.qualifyEvent[i].value; } } =09 if (document.calform.qualifyEvent[0].checked) // add/change/delete { =09 if = (document.calform.qualifyEventType.options[document.calform.qualifyEventT= ype.selectedIndex].value =3D=3D "0"){ if (document.calform.whatLanguage.value =3D=3D"1")=20 {window.alert("Por favor seleccione el tipo de evento = beneficiarias."); } else {window.alert("Please select the Qualifying Event Type"); } document.calform.qualifyEventType.focus();=20 return false; } =09 =09 if = (document.calform.chgMonth.options[document.calform.chgMonth.selectedInde= x].value =3D=3D "0"){ if (document.calform.whatLanguage.value =3D=3D"1")=20 {window.alert("Fecha del suceso - Mes"); } else {window.alert("Qualifying Event Date - Month"); } document.calform.chgMonth.focus();=20 return false; } =09 if = (document.calform.chgDay.options[document.calform.chgDay.selectedIndex].v= alue =3D=3D "0"){ if (document.calform.whatLanguage.value =3D=3D"1")=20 {window.alert("Fecha del suceso - D=EDa"); } else {window.alert("Qualifying Event Date - Day"); } document.calform.chgDay.focus();=20 return false; } =09 if = (document.calform.chgYear.options[document.calform.chgYear.selectedIndex]= .value =3D=3D "0"){ if (document.calform.whatLanguage.value =3D=3D"1")=20 {window.alert("Fecha del suceso - Ano"); } else {window.alert("Qualifying Event Date - Year"); } document.calform.chgYear.focus();=20 return false; } =09 //validate date of event=09 var daYearr =3D = document.calform.chgYear.options[document.calform.chgYear.selectedIndex].= value; var daMonthh =3D = document.calform.chgMonth.options[document.calform.chgMonth.selectedIndex= ].value; var daDayy =3D = document.calform.chgDay.options[document.calform.chgDay.selectedIndex].va= lue; =09 if (IsValidDate(daDayy,daMonthh,daYearr) =3D=3D false) { if (document.calform.whatLanguage.value =3D=3D"1")=20 {window.alert("Fecha del suceso"); } else {window.alert("Event date is invalid"); } document.calform.chgMonth.focus();=20 return false; } =09 //OK to allow for future dates so this code has been removed =09 var DateVal =3D daMonthh + "/" + daDayy + "/" + daYearr; var dte =3D new Date(DateVal); var dteNow =3D new Date(); var dteExp =3D new Date(dte); =09 if(dteExp > dteNow )=20 {alert("Date must be before today."+ '\n' + "La fecha debe de ser = antes de hoy."); document.calform.chgMonth.focus();=20 return false;=09 }=09 =09 } if (document.calform.qualifyEvent[1].checked) { if = (!ValField(document.calform.qualifyEventNameFrom,'an',2,30,'y','Name = Changed From','Cambio de nombre')) return false; if (IsNumeric(document.calform.qualifyEventNameFrom.value) =3D=3D = true) {callAlert(document.calform.qualifyEventNameFrom,'Name Changed = From','Cambio de nombre'); return false;} } // Renewal Period if (document.calform.qualifyEvent[6].checked) {=20 if = (document.calform.renewPeriod.options[document.calform.renewPeriod.select= edIndex].value =3D=3D "0") { =09 window.alert("A renewal period is required"); document.calform.renewPeriod.focus();=20 return false;} } =09 } =09 //PLAN SELECTION if (valButtonOne(document.calform.premAmount) =3D=3D false) { if (document.calform.whatLanguage.value =3D=3D"1")=20 { window.alert("Seleccione una opcion en virtud del Plan de = Selecci=F3n");} else { window.alert("Please select an option under the Plan Selection"); = } document.calform.premAmount[0].focus(); return false;} =09 //VISION PLAN SELECTION if (valButtonOne(document.calform.visCoverage) =3D=3D false) { if (document.calform.whatLanguage.value =3D=3D"1")=20 { window.alert("Le gustaria agregar cobertura de Vision a su plan = dental?");} else { window.alert("Do you want add vision to your dental plan?"); }=09 document.calform.visCoverage[0].focus(); return false;} =09 //FIRST, LAST, MIDDLE INITIAL =09 if (!ValField(document.calform.memberFirst,'an',1,25,'y','First = Name','Nombre del solicitante')) return false; =20 if (IsNumeric(document.calform.memberFirst.value) =3D=3D true) {callAlert(document.calform.memberFirst,'First Name','Nombre del = solicitante'); return false;}=09 =09 if (!ValField(document.calform.memberLast,'an',2,25,'y','Last = Name','Apellido del solicitante')) return false; if (IsNumeric(document.calform.memberLast.value) =3D=3D true) {callAlert(document.calform.memberLast,'Last Name','Apellido del = solicitante'); return false;}=09 =20 // if (!ValField(document.calform.memberInitial,'a',1,1,'n','Middle = Initial','Inicial de su segundo nombre')) return false; // if (IsNumeric(document.calform.memberInitial.value) =3D=3D true) // {callAlert(document.calform.memberInitial,'Middle = Initial','Inicial de su segundo nombre'); // return false;}=09 =20 //SOCIAL SECURITY NUMBER =20 if (!ValField(document.calform.memberNum,'n',9,9,'y','Social = Security Number or Employee ID','Numero de Seguro Social' )) return = false; =09 =09 //MARITAL STATUS=09 if = (document.calform.memberMarital.options[document.calform.memberMarital.se= lectedIndex].value =3D=3D "0") { window.alert("Marital Status information is missing"+ '\n' + = "Estado civil es la informaci=F3n faltante"); document.calform.memberMarital.focus();=20 return false;} =09 =09 //GENDER if = (document.calform.memberGender.options[document.calform.memberGender.sele= ctedIndex].value =3D=3D "0") { window.alert("Gender information is missing." + '\n' + "Sexo = es la informacion faltante"); document.calform.memberGender.focus();=20 return false;} =09 =09 // DOB MONTH=09 if = (document.calform.dobMonth.options[document.calform.dobMonth.selectedInde= x].value =3D=3D "0"){ if (document.calform.whatLanguage.value =3D=3D"1")=20 {window.alert("Fecha de nacimiento - Mes"); } else {window.alert("Birthday - Month"); } document.calform.dobMonth.focus();=20 return false; } =09 //DOB DAY=09 if = (document.calform.dobDay.options[document.calform.dobDay.selectedIndex].v= alue =3D=3D "0"){ if (document.calform.whatLanguage.value =3D=3D"1")=20 {window.alert("Fecha de nacimiento - D=EDa"); } else {window.alert("Birthday- Day"); } document.calform.dobDay.focus();=20 return false; } =09 =09 //DOB YEAR=09 =09 if = (document.calform.dobYear.options[document.calform.dobYear.selectedIndex]= .value =3D=3D "0"){ if (document.calform.whatLanguage.value =3D=3D"1")=20 {window.alert("Fecha de nacimiento - Ano"); } else {window.alert("Birthday - Year"); } document.calform.dobYear.focus();=20 return false; } =09 =09 //Validate DOB var daYearr =3D = document.calform.dobYear.options[document.calform.dobYear.selectedIndex].= value; var daMonthh =3D = document.calform.dobMonth.options[document.calform.dobMonth.selectedIndex= ].value; var daDayy =3D = document.calform.dobDay.options[document.calform.dobDay.selectedIndex].va= lue; =09 if (IsValidDate(daDayy,daMonthh,daYearr) =3D=3D false) { if (document.calform.whatLanguage.value =3D=3D"1")=20 {window.alert("Fecha de nacimiento"); } else {window.alert("Date of Birth is invalid"); } document.calform.dobMonth.focus();=20 return false; } =09 var DateVal =3D daMonthh + "/" + daDayy + "/" + daYearr; var dte =3D new Date(DateVal); var dteNow =3D new Date(); var dteExp =3D new Date(dte); =09 if(dteExp > dteNow )=20 {alert("Date must be before today."+ '\n' + "Debe ser antes de la = fecha de hoy."); document.calform.dobMonth.focus();=20 return false;=09 }=09 =09 =09 var DateVal =3D daMonthh + "/" + daDayy + "/" + daYearr; var dte =3D new Date(DateVal); var dteNow =3D new Date(); var dteExp =3D new Date(dte); =09 if(dteExp > dteNow )=20 {alert("Date must be before today."+ '\n' + "Debe ser antes de la = fecha de hoy."); document.calform.dobMonth.focus();=20 return false;=09 }=09 =09 //***********************=09 //Applicants must be over 18 years old // 365 days * 18 Years =3D 6570 if(days_between(dteNow, dteExp) < 6570 )=20 {alert("Only Az residents 18 years of age or older qualify to be = Subscribers on the Individual Plan."+ '\n' + "Solo residentes de Az = mayores de 18 anos califican para ser subscriptores del plan individual = "); document.calform.dobMonth.focus();=20 return false;=09 }=09 =09 //ADDRESS, CITY , ZIP if (!ValField(document.calform.memberAddress,'an',5,50,'y','Home = Address (Mailing) ','Direccion de hogar (de correo) ')) return false; if (IsNumeric(document.calform.memberAddress.value) =3D=3D true) {callAlert(document.calform.memberAddress,'Home Address = (Mailing)','Direccion de hogar (de correo)'); return false;}=09 =09 if = (!ValField(document.calform.memberCity,'a',2,50,'y','City','Ciudad ')) = return false; if (IsNumeric(document.calform.memberCity.value) =3D=3D true) {callAlert(document.calform.memberCity,'City','Ciudad'); return false;}=09 =09 if (!ValField(document.calform.memberZip,'n',5,5,'y','Zip = Code','Codigo Postal ')) return false; =09 //PHONE if (!ValField(document.calform.memberPhone,'n',10,10,'y','Home Phone = Number','Telefono residencial')) return false; =09 //EMAIL =09 if (!isEmail(document.calform.memberEmail)) return false;=09 =09 =09 =09 return true; } =20 //end function setupA // show hide function for family vs individual coverage function unHider() { document.all.div1.style.display =3D 'block'; } =09 function hider() { document.all.div1.style.display =3D 'none'; } function showVisionOptions() { if = ((document.calform.visionOPT.options[calform.visionOPT.selectedIndex].val= ue =3D=3D "VIS")) { unHider(); document.calform.visionOPT.focus(); }else { hider();=20 } } // =09 function setupVisA(){ //VISION PLAN SELECTION if (valButtonOne(document.calform.visCoverage) =3D=3D false) { if (document.calform.whatLanguage.value =3D=3D"1")=20 { window.alert("Le gustaria agregar cobertura de Vision a su plan = dental?");} else { window.alert("Select the Vision coverage plan?"); }=09 document.calform.visCoverage[0].focus(); return false;} =09 =09 // DENTAL GROUP NUMBER if (!ValField(document.calform.planGroupID,'an',5,5,'y','Dental Group = Number','Dental Group Number ')) return false; var str=3Ddocument.calform.planGroupID.value; var locstr=3Dstr.indexOf('8'); if (locstr !=3D 1) {window.alert('The group number entered is invalid '+str+'.'); document.calform.planGroupID.focus(); return false;} =09 //FIRST, LAST, MIDDLE INITIAL =09 if (!ValField(document.calform.memberFirst,'an',1,25,'y','First = Name','Nombre del solicitante')) return false; =20 if (IsNumeric(document.calform.memberFirst.value) =3D=3D true) {callAlert(document.calform.memberFirst,'First Name','Nombre del = solicitante'); return false;}=09 =09 if (!ValField(document.calform.memberLast,'an',2,25,'y','Last = Name','Apellido del solicitante')) return false; if (IsNumeric(document.calform.memberLast.value) =3D=3D true) {callAlert(document.calform.memberLast,'Last Name','Apellido del = solicitante'); return false;}=09 =20 // if (!ValField(document.calform.memberInitial,'a',1,1,'n','Middle = Initial','Inicial de su segundo nombre')) return false; // if (IsNumeric(document.calform.memberInitial.value) =3D=3D true) // {callAlert(document.calform.memberInitial,'Middle = Initial','Inicial de su segundo nombre'); // return false;}=09 =20 //SOCIAL SECURITY NUMBER =20 if (!ValField(document.calform.memberNum,'n',9,9,'y','Social = Security Number','Numero de Seguro Social' )) return false; =09 =09 //MARITAL STATUS=09 if = (document.calform.memberMarital.options[document.calform.memberMarital.se= lectedIndex].value =3D=3D "0") { window.alert("Marital Status information is missing"+ '\n' + = "Estado civil es la informaci=F3n faltante"); document.calform.memberMarital.focus();=20 return false;} =09 =09 //GENDER if = (document.calform.memberGender.options[document.calform.memberGender.sele= ctedIndex].value =3D=3D "0") { window.alert("Gender information is missing." + '\n' + "Sexo = es la informacion faltante"); document.calform.memberGender.focus();=20 return false;} =09 =09 // DOB MONTH=09 if = (document.calform.dobMonth.options[document.calform.dobMonth.selectedInde= x].value =3D=3D "0"){ if (document.calform.whatLanguage.value =3D=3D"1")=20 {window.alert("Fecha de nacimiento - Mes"); } else {window.alert("Birthday - Month"); } document.calform.dobMonth.focus();=20 return false; } =09 //DOB DAY=09 if = (document.calform.dobDay.options[document.calform.dobDay.selectedIndex].v= alue =3D=3D "0"){ if (document.calform.whatLanguage.value =3D=3D"1")=20 {window.alert("Fecha de nacimiento - D=EDa"); } else {window.alert("Birthday- Day"); } document.calform.dobDay.focus();=20 return false; } =09 =09 //DOB YEAR=09 =09 if = (document.calform.dobYear.options[document.calform.dobYear.selectedIndex]= .value =3D=3D "0"){ if (document.calform.whatLanguage.value =3D=3D"1")=20 {window.alert("Fecha de nacimiento - Ano"); } else {window.alert("Birthday - Year"); } document.calform.dobYear.focus();=20 return false; } =09 =09 //Validate DOB var daYearr =3D = document.calform.dobYear.options[document.calform.dobYear.selectedIndex].= value; var daMonthh =3D = document.calform.dobMonth.options[document.calform.dobMonth.selectedIndex= ].value; var daDayy =3D = document.calform.dobDay.options[document.calform.dobDay.selectedIndex].va= lue; =09 if (IsValidDate(daDayy,daMonthh,daYearr) =3D=3D false) { if (document.calform.whatLanguage.value =3D=3D"1")=20 {window.alert("Fecha de nacimiento"); } else {window.alert("Date of Birth is invalid"); } document.calform.dobMonth.focus();=20 return false; } =09 var DateVal =3D daMonthh + "/" + daDayy + "/" + daYearr; var dte =3D new Date(DateVal); var dteNow =3D new Date(); var dteExp =3D new Date(dte); =09 if(dteExp > dteNow )=20 {alert("Date must be before today."+ '\n' + "Debe ser antes de la = fecha de hoy."); document.calform.dobMonth.focus();=20 return false;=09 }=09 =09 =09 =09 =09 =09 //ADDRESS, CITY , ZIP if (!ValField(document.calform.memberAddress,'an',5,50,'y','Home = Address (Mailing) ','Direccion de hogar (de correo) ')) return false; if (IsNumeric(document.calform.memberAddress.value) =3D=3D true) {callAlert(document.calform.memberAddress,'Home Address = (Mailing)','Direccion de hogar (de correo)'); return false;}=09 =09 if = (!ValField(document.calform.memberCity,'a',2,50,'y','City','Ciudad ')) = return false; if (IsNumeric(document.calform.memberCity.value) =3D=3D true) {callAlert(document.calform.memberCity,'City','Ciudad'); return false;}=09 =09 if (!ValField(document.calform.memberZip,'n',5,5,'y','Zip = Code','Codigo Postal ')) return false; =09 //PHONE if (!ValField(document.calform.memberPhone,'n',10,10,'y','Home Phone = Number','Telefono residencial')) return false; =09 //EMAIL =09 if (!isEmail(document.calform.memberEmail)) return false;=09 =09 // Go to the second part of this function / part b is no group coverage = and 12 month confirmation info =20 var entityName =3D "Delta Dental of Arizona"; if (!document.calform.proofAgree[0].checked) { =20 if (document.calform.whatLanguage.value =3D=3D"1")=20 { window.alert("Por favor, seleccione acepto con respecto a no ser = elegibles para la cobertura "+ entityName+" a trav=E9s de = empleador.");} else { window.alert("Please select checkbox regarding current membersip = in "+ entityName+" Individual and Family Plans dental coverage."); } = =20 document.calform.proofAgree[0].focus();=20 document.calform.proofAgree[0].select();=20 return false;} =09 =09 =09 if (!document.calform.proofAgree[1].checked) { =20 if (document.calform.whatLanguage.value =3D=3D"1")=20 { window.alert("Por favor, seleccione acepto en relacion con la = obligaci=F3n de 12 meses de inscripci=F3n.");} else { window.alert("Please select checkbox regarding the mandatory 12 = month enrollment period."); } =20 document.calform.proofAgree[1].focus();=20 document.calform.proofAgree[1].select();=20 return false;} =09 } function days_between(date1, date2) { // The number of milliseconds in one day var ONE_DAY =3D 1000 * 60 * 60 * 24 =09 // Convert both dates to milliseconds var date1_ms =3D date1.getTime() var date2_ms =3D date2.getTime() =09 // Calculate the difference in milliseconds var difference_ms =3D Math.abs(date1_ms - date2_ms) =09 // Convert back to days and return return Math.round(difference_ms/ONE_DAY) } ------=_NextPart_000_0000_01CBC2AB.76E275A0 Content-Type: application/octet-stream Content-Transfer-Encoding: quoted-printable Content-Location: https://www.deltadentalaz.com/secured/eforms/inc_formValidation.js
PAYMENT=20 OPTIONS
Monthly EFT Payment = Option=20
Monthly EFT from a checking account for the = selected=20 plan(s).		 Monthly EFT=20 Payment Option  
Annual Payment=20 Option
Requires a 12 month payment for the = selected=20 plan(s) by credit card or e-check.		 Annual = Payment=20 Option