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<head>
    <title>Annual Survey - Ohio Health Insurance Business</title>
    <meta content="Microsoft Visual Studio.NET 7.0" name="GENERATOR" />
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            <div class="FrmTitleBackGrnd" style="font-weight: bold; color: #000000;">
                Annual Report of Ohio Health Insurance Business - Submit Data Page
                          <a style="margin-left: 150px;" class="main" onmouseover="window.status='Context Sensitive Help';return true;" onmouseout="window.status='';return true;"
                              href="Instructions/Help.pdf" target="helpwindow">Help</a>
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                <table width="100%" border="0" role="presentation">
                    <tr valign="baseline">
                        <td width="14">
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                        <td class="FrmInfo" height="20">Data for<b>
                            <asp:Label ID="lblCompanyName" runat="server"></asp:Label></b></td>
                    </tr>
                    <tr valign="baseline">
                        <td width="14">
                            <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="14">
                            <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="FrmError" colspan="2">
                            <asp:ValidationSummary ID="vsError" runat="server" HeaderText="PLEASE CORRECT THE FOLLOWING ERROR(S):"
                                CssClass="frmError" Width="100%" EnableViewState="False" ShowMessageBox="True"></asp:ValidationSummary>
                        </td>
                    </tr>
                    <tr>
                        <td class="FrmError" colspan="2">
                            <asp:Label ID="lblError" runat="server" EnableViewState="False"></asp:Label></td>
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            <div class="FrmBackGrnd" style="margin: 5px;">
                <p class="FrmInfo"><b>SUBMIT DATA</b></p>
                <asp:Label ID="lblTotals" runat="server" CssClass="frmError"></asp:Label>
                <asp:Panel ID="pnTotals" Visible="false" runat="server">
                    <div class="FrmInfo">
                        <table cellspacing="0" cellpadding="0" border="0" role="presentation">
                            <tr>
                                <td width="30%">&nbsp;</td>
                                <td class="frmError" align="right">Direct Premium Earned</td>
                                <td width="5%" rowspan="4">&nbsp;</td>
                                <td class="frmError" align="right">Direct Claims Incurred</td>
                            </tr>
                            <tr>
                                <td class="frmError">Company Data</td>
                                <td align="right">
                                    <asp:Label ID="lblDirPremium" runat="server" CssClass="frmError"></asp:Label></td>
                                <td align="right">
                                    <asp:Label ID="lblDirClaims" runat="server" CssClass="frmError"></asp:Label></td>
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                            <tr>
                                <td class="frmError">NAIC Totals</td>
                                <td align="right">
                                    <asp:Label ID="lblNAICDirPremium" runat="server" CssClass="frmError"></asp:Label></td>
                                <td align="right">
                                    <asp:Label ID="lblNAICDirClaims" runat="server" CssClass="frmError"></asp:Label></td>
                            </tr>
                            <tr>
                                <td class="frmError">Difference</td>
                                <td align="right">
                                    <asp:Label ID="lblDiffDirPremium" runat="server" CssClass="frmError"></asp:Label></td>
                                <td align="right">
                                    <asp:Label ID="lblDiffDirClaims" runat="server" CssClass="frmError"></asp:Label></td>
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                </asp:Panel>
                <asp:Panel ID="pnComment" Visible="false" runat="server">
                    <table cellspacing="0" cellpadding="0" width="100%" border="0" role="presentation">
                        <tr>
                            <td class="FrmFieldTxt" valign="middle" width="10%">Explanatory&nbsp;<br />
                                Comment&nbsp;</td>
                            <td width="90%">
                                <asp:TextBox ID="txtComment" runat="server" Rows="5" Columns="40" TextMode="MultiLine"></asp:TextBox>
                                <asp:RequiredFieldValidator ID="rfvComment" runat="server" CssClass="frmError" ErrorMessage="Please give Explanatory Comment."
                                    Display="Static" Enabled="false" Text="?" Font-Bold="true" ControlToValidate="txtComment"></asp:RequiredFieldValidator>
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                    <table cellspacing="0" cellpadding="0" border="0" role="presentation">
                        <tr>
                            <td>

                                <asp:CheckBox ID="chkConfirm" runat="server" CssClass="medfont" Text="Have you completed data entry for all the categories applicable to your company?"
                                    TextAlign="right"></asp:CheckBox>&nbsp;
																								    <asp:CustomValidator ID="cuvConfirm" runat="server" CssClass="frmError" Font-Bold="True" ErrorMessage="Please click on the check box before clicking on Confirm button."
                                                                                                        ClientValidationFunction="Validate">?</asp:CustomValidator>
                            </td>
                        </tr>
                        <tr>
                            <td>&nbsp;</td>
                        </tr>
                        <tr>
                            <td>
                                <asp:Button ID="cmdSubmitData" runat="server" Text="Submit Data"></asp:Button></td>
                        </tr>
                        <tr>
                            <td>&nbsp;</td>
                        </tr>
                    </table>
                </div>
                <p class="FrmInfo"><b>Print the Completed Report</b></p>
                <p class="FrmInfo">Print a copy of the completed report for your records.</p>
                <table cellspacing="0" cellpadding="0" width="100%" border="0" role="presentation">
                    <tr>
                        <td class="FrmFieldTxt" width="33%">
                            <div align="left">Plan Year for the Report&nbsp;</div>
                        </td>
                        <td width="67%">
                            <asp:DropDownList ID="ddlReportYear" runat="server"></asp:DropDownList></td>
                    </tr>
                    <tr>
                        <td colspan="2">&nbsp;</td>
                    </tr>
                    <tr>
                        <td colspan="2" height="20">
                            <input id="PrintReport" onclick="dothis()" type="button" value="Print Report" name="Print Report" />
                        </td>
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                args.IsValid = false; //For Custom Validator
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        }

        function dothis() {
            var strURL;
            var strYear;

            strYear = document.getElementById("ddlReportYear").value;
            strURL = "Report.aspx?ReportYear=" + strYear;
            //  strURL = "/LHSurvey/crystalreport.aspx?ReportID=12260&ReportYear=" + strYear;
            //	document.location.href = strURL;
            window.open(strURL, 'myname', 'resizable=yes,statusbar,menubar,scrollbars,toolbar,left=25,top=35,width=740,height=400');
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