I'm builiding an online insurance application, where people input thier data, and it gives them rates, then lets them apply. I was wondering if someone could take a look and maybe tell me what the issue is?

Here is the url: http://67.62.217.33/test5

You will need to supply a valid zip, as it does a check for areas the insurance is available. You can use 23834

The issue I'm having is on the the next page...