Create Javascript Dropdown Menu for Insurance Lead Gen Site

I have a pretty quick project: I'm building an insurance lead gen website, and I've created a dropdown box for people to choose their state and type of insurance they want (you can view it at [login to view URL]). I am looking for someone to create the functionality to that when someone chooses their state and type of insurance they're brought to a results page. That page is populated with Javascript provided by an affiliate which will show insurance providers in the area. The only catch: 1 of the types of insurance in the dropdown uses a different affiliate (and different javascript for the landing page). The site is built on Wordpress. You can get a good idea of how this is supposed to work by looking at healthinsurancefinders.com. I'm happy to answer any questions.