<%@ Page Language="vb" AutoEventWireup="false" CodeBehind="SbrgtnRcvrs.aspx.vb" Inherits="LHSurvey.SbrgtnRcvrs" %>

<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html xmlns="http://www.w3.org/1999/xhtml" lang="en-US">
<head>
    <title>Annual Survey - Ohio Health Insurance Business</title>
    <meta content="Microsoft Visual Studio.NET 7.0" name="GENERATOR" />
    <meta content="Visual Basic 7.0" name="CODE_LANGUAGE" />
    <meta content="JavaScript" name="vs_defaultClientScript" />
    <meta content="http://schemas.microsoft.com/intellisense/ie5" name="vs_targetSchema" />
    <meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1" />
    <link href="style.css" type="text/css" rel="stylesheet" />


    <script type="text/javascript" language="javascript">

        function ValidateSubrgtnAmount(source, arg) {
            var RE = /^-{0,1}\d*\.{0,1}\d+$/;
            if (RE.test(arg.Value))
                return true;
            else {
                alert('Total Annual Amount is not a valid number');
                return false;
            }
        }

    </script>
</head>
<body style="background: #ffffff">
  <form id="Form2" method="post" runat="server">
        <input id="hidRecordExist" type="hidden" name="hidRecordExist" runat="server" />
       <div style="margin-left: 315px; margin-top:10px; border-spacing: 0px; padding: 0px; width: 669px; height:735px;" class="FrmTable" align="center">
            <div class="FrmTitleBackGrnd" style="font-weight: bold; color: #000000; padding-left:5px;" align="left">
                Annual Report of Ohio Health Insurance Business - <br />Subrogation Recovery Information
                          <a style="margin-left: 390px;" class="main" onmouseover="window.status='Context Sensitive Help';return true;" onmouseout="window.status='';return true;"
                              href="Instructions/Help.pdf" target="helpwindow">Help</a>
            </div>
            <div class="FrmBackGrnd" style="margin: 5px;">
                <table width="100%" border="0" role="presentation">
                    <tr valign="baseline">
                        <td width="20" style="width: 20px">
                            <img src="/images/frmBullet.gif" alt=""/></td>
                        <td class="FrmInfo" width="484" height="20">Data for <b>
                            <asp:Label ID="lblCompanyName" runat="server"></asp:Label></b></td>
                    </tr>
                    <tr valign="baseline">
                        <td width="20" style="width: 20px">
                            <img src="/images/frmBullet.gif" alt=""/></td>
                        <td class="FrmInfo" height="20">NAIC Number:<b>
                            <asp:Label ID="lblNaicNum" runat="server"></asp:Label></b></td>
                    </tr>
                    <tr valign="baseline">
                        <td width="20" style="width: 20px">
                            <img src="/images/frmBullet.gif" alt=""/></td>
                        <td class="FrmInfo" height="20"><b>INFORMATION RELATED ONLY TO BUSINESS IN OHIO</b></td>
                    </tr>
                    <tr valign="baseline">
                        <td width="14">
                            <img src="/images/frmBullet.gif" alt=""/></td>
                        <td height="20" class="FrmInfo">
                            <b>REPORTING FOR THE PREVIOUS YEAR BEGINS MID-MARCH</b></td>
                    </tr>
                    <tr valign="baseline">
                        <td width="14">
                            <img src="/images/frmBullet.gif" alt=""/></td>
                        <td height="20" class="FrmInfo">
                            <b>CURRENTLY VIEWING FOR THE YEAR ENDING
															<asp:Label ID="lblPeriod" runat="server"></asp:Label></b></td>
                    </tr>
                    <tr>
                        <td class="FrmInfo" style="height: 19px" valign="bottom" colspan="2" height="19">
                            <p style="font-size:1em;"><b>INSTRUCTIONS:</b></p>
                        </td>
                    </tr>
                    <tr valign="baseline">
                        <td style="width: 20px; height: 39px" width="20">
                            <img src="/images/frmBullet.gif" alt=""/></td>
                        <td class="FrmInfo" style="height: 39px" height="39">
                            <p>
                                <strong><span style="font-size: 1em">For 
																	    purposes of this reporting, "subrogation recovery" is defined as recovery of 
																	    medical expenses on behalf of&nbsp; an insured, where those medical expenses 
																	    were&nbsp;subsequently reimbursed to the insurer by another lawfully liable 
																	    party.</span></strong>
                            </p>
                        </td>
                    </tr>
                    <tr valign="baseline">
                        <td style="width: 20px; height: 33px" width="20">
                            <img src="/images/frmBullet.gif" alt=""/></td>
                        <td class="FrmInfo" style="height: 33px;"><strong><span style="font-size:1em;">Report one 
															    combined total for all product types.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
														    &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
														    &nbsp;&nbsp;&nbsp;&nbsp; (EXCLUDES: All Disability products &amp; Excess / Stop 
														    Loss)</span></strong>
                        </td>
                    </tr>
                    <tr valign="baseline">
                        <td width="20" style="width: 20px">
                            <img src="/images/frmBullet.gif" alt=""/></td>
                        <td class="FrmInfo" height="20"><b>ALL FIELDS MUST BE COMPLETED. 0 dollar amount is 
														    permissible.</b>
                        </td>
                    </tr>
                    <tr valign="baseline">
                        <td width="17" style="width: 20px; height: 18px">
                            <img src="/images/frmBullet.gif" alt=""/></td>
                        <td class="FrmInfo" height="18" style="height: 18px"><b>SAVE DATA BEFORE LEAVING THIS 
														    PAGE. </b>
                        </td>
                    </tr>
                    <tr>
                        <td class="FrmError" colspan="2">
                            <asp:ValidationSummary ID="vsError" runat="server" EnableViewState="False" ShowMessageBox="True" ShowSummary="false" CssClass="frmError"
                                HeaderText="PLEASE CORRECT THE FOLLOWING ERROR(S):" Width="100%"></asp:ValidationSummary>
                        </td>
                    </tr>
                    <tr>
                        <td class="FrmError" colspan="2">
                            <asp:Label ID="lblError" runat="server" EnableViewState="False"></asp:Label></td>
                    </tr>
                </table>
            </div>
            <div class="FrmBackGrnd" style="margin: 5px;">
                <table style="width: 584px; height: 118px" cellspacing="0" cellpadding="2" width="584"
                    border="1" role="presentation">
                    <tr>
                        <td bgcolor="#cccccc" colspan="2" height="24"><span class="FrmSecHead">Does your 
																	    company pursue subrogation for Medical Claims 
																	    Expenses?&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
																	    &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
																	    &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
																	    Must select Yes or&nbsp;No from drop down: (<em>required field</em>)</span>
                        </td>
                    </tr>
                    <tr style="border-top-style: none; border-right-style: none; border-left-style: none; border-bottom-style: none">
                        <td style="height: 79px" colspan="2">
                            <p align="center">
                                <asp:DropDownList ID="ddlSubrgtn_flag" runat="server"
                                    Width="78px">
                                    <asp:ListItem Selected="True"></asp:ListItem>
                                    <asp:ListItem Value="Y">Yes</asp:ListItem>
                                    <asp:ListItem Value="N">No</asp:ListItem>
                                </asp:DropDownList>&nbsp;
							    <asp:RequiredFieldValidator ID="rfvSubflg" runat="server" Font-Bold="True" ErrorMessage="Must select Yes or No from drop down"
                                     ControlToValidate="ddlSubrgtn_flag">?</asp:RequiredFieldValidator>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
							        &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
                            </p>
                        </td>
                    </tr>
                </table>
                <table style="width: 584px; height: 99px; margin:10px;" cellspacing="0" cellpadding="2" width="584"
                   border="1" role="presentation">
                   <tr>
                       <td bgcolor="#cccccc" colspan="2" height="24"><span class="FrmSecHead">Provide the 
																	    total&nbsp; annual $ amount of&nbsp;&nbsp;subrogation recoveries for medical 
																	    claims expenses.&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 
																	    &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Must enter an amount. 0 is 
																	    permissible. (<em>required field</em>)</span></td>
                   </tr>
                   <tr>
                       <td class="FrmFieldTxt" style="height:79px" colspan="2">
                           <p align="center">
                               &nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
				     <asp:TextBox ID="SbrgtnAmount" runat="server" Width="250px"></asp:TextBox>&nbsp;<asp:RequiredFieldValidator ID="rfvSubrgtnAmt" runat="server" Width="3px" Font-Bold="True" ErrorMessage="Must enter an amount. 0 is permissable."
                                                                                        ControlToValidate="SbrgtnAmount">?</asp:RequiredFieldValidator>
                               <asp:CustomValidator ID="CustomValidator1" runat="server" Width="14px" Font-Bold="True" ErrorMessage="Must enter an amount. 0 is permissable."
                                   ControlToValidate="SbrgtnAmount" ClientValidationFunction="ValidateSubrgtnAmount">?</asp:CustomValidator>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;
                           </p>
                       </td>
                   </tr>
               </table>
            </div>
            <div class="FrmBackGrnd" align="right">
                    <asp:Button ID="cmdSave" OnClick="cmdSave_Click" runat="server" Text="Save"></asp:Button>&nbsp;&nbsp;&nbsp;
             </div>
        </div>
     </form>
</body>
</html>

