document.writeln(' <table border=0 cellpadding=0 cellspacing=0  width=100%  bgcolor=#bg4141 style="font-size: 10 pt; color: #FFFFFF; font-family: Arial;	border: 1 solid #FFFFFF">') 
document.writeln('   <form name="adventor9539" action="http://www.adventor.nl/antwoord2.asp">') 
document.writeln('   <tr><td colspan=2 bgcolor=#FFFFFF style="font-size: 10 pt; color: #000000; font-family: Arial"  ><b>Autoverzekeringscheck</b></td></tr>') 
document.writeln('   <tr><td colspan=2><b>Is uw navigatiesysteem meeverzekerd?</b></td></tr>') 
document.writeln(' <tr><td colspan=2>&nbsp;</td></tr>') 
document.writeln('   <tr><td width=5% valign=top><input type=radio value=1 name=Antw></td>') 
document.writeln('     <td align=left width=95% >Ja</td></tr>') 
document.writeln('   <tr><td width=5% valign=top><input type=radio value=2 name=Antw></td>') 
document.writeln('     <td align=left width=95% >Nee</td></tr>') 
document.writeln(' <tr><td colspan=2>&nbsp;</td></tr>') 
document.writeln('   <tr><td colspan=2  bgcolor=#bg4141>') 
document.writeln(' <input type=submit value="Check" name=B1></td>') 
document.writeln('   <input type=hidden name="SiteID" value="8117">') 
document.writeln('   <input type=hidden name="VraagID" value="9539">') 
document.writeln('   <input type=hidden name="PollBasisId" value="5140">') 
document.writeln(' </tr></form></table>')