HTML/CSS Edits to one page, some JS and PHP

General information for the website: Insurance Comparison Site
Kind of development: Customization of existing website
Num. of web pages/modules: 1
Description of every page/module: We need a form on our website edited to have a slightly different layout and one new field added.
Description of requirements/features: I have created a document that outlines in more detail what we require (New Funeral Product form.pdf) but the summary is as follows:

1) Remove one field on form and replace this with a new field. Take visual assets for this new field from another form on our site
2) Change layout of form from "1 old form.png" layout to "2 Funeral form - not annotated.png" layout
3) Removal of one JS validation rule
4) Add the new field to our POST form processing php file. No extra validation required.
Extra notes: I have included a third screenshot, "3 Funeral form - annotated.png", which shows in more detail what we require for point 2 above. This expands on the information in the attached PDF file.

I will supply a zip file of the PHP/CSS/JS files to the winning freelancer.

Please note: the new form must be tested and work in most popular browsers. (IE, Firefox, Chrome, Safari - and tablets). I will test the form with BrowserStack.com to ensure that it works.