Basic Info Form w/E-mail reply

Hello. I need a basic form created for an insurance based website. Basically, it needs to include the same information found on this form page: [login to view URL] The problem with that page is simple--it is too cluttered. So I'd like to re-do the form page(s) into probably 3 separate pages, so that each page looks much less challenging to a potential applicant. Clients should be able to navigate between the pages to change info until they hit a final "submit" button. Upon "submit," the info should be generated to an email account I will specify, at which point the client is directed to a "thank you" page. An auto-reply email should also be generated upon final submit. On certain lines, clients should be prohibited from entering, or not entering, certain info. It should look the same, and function the same, in IE6+ and Foxfire. The form can be cgi or php, but ideally should not contain java scripts if at all possible (although it does need to "check" for completion errors before submission). Also, the form itself (including all 3 pages) needs a spiffy little update to look nicer and more inviting--nothing fancy, just clean and functional but more professional than it currently looks. (In fact, I have more design work to do after this, so hopefully the winner will be someone who is also a top-notch graphics & website designer. So although this should be a relatively low priced bid, because it is so simple, there could be more work down the road in the near future.) The link provided above is not on a secured site, but we do use a secured connection to complete the form. Ideally the new form will be written in a way so that nobody gets an "alert" message asking them whether they want to display any non-secured items (there are a couple of icons that have caused such problems on our secured page version--I can provide a link if you would like to see the "problem" up front). Please include links to samples of your work--other form information pages would be very helpful. Automated replies will be ignored. Please include this code in your response: eagle07 I am U.S. based and prefer english speaking individual(s) to work with. The ability to contact via telephone would be a bonus. This project, upon acceptance, needs to be completed in the next few days! Upon acceptance, I will provide specific details via email as to what information the form should contain and in what order. Thanks for your interest!