Contest $20 EASY Insurance Zip Code Header!

Ok, basically I have a website , about medical insurance, and I already have a header, but I want you to make something like this,

http://healthinsurancedeals.org/
http://myhealthinsurancerates.net/

Where you see the zip code box, I want someone to create something like that I can easily edit in a psd (change colors, size). Please watermark your samples so you won't think im stealing

However, even though I want the box to look like the previous 2 sites, keep it mind that it will have forms like these.

http://www.insurancehotline.com/

I hope this is clear enough for now.

BTW, I am not looking for a new header image, just that zip code box I can implement ON TOP of my header!

Also note if you know how to code this into the website, please pm so we can work out the payment after I get an image I like!

 

Found a designer who contacted me. I will close it now.......

 

PM ME FOR DESIRED DESIGNS @ PREFERRED PRICES!

 

Ok guys, you have the basic idea, although I need it to be more professional.

You can take away the USA canada tab, and make the quote area bigger, such as the urls I provided.

 

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Updated entry.

 

Thanks for the attempt, but someone designed one in pm i was satisfied with.

http://i46.tinypic.com/2ywy780.jpg