Gecko [ dp-client.com ]

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.mad-root	0 B	-rw-r--r--
dashbord.php	58.95 KB	-rw-r--r--
index.php	5.1 KB	-rw-r--r--
insurance-listing.php	30.73 KB	-rw-r--r--
policy-dashboard.php	48.69 KB	-rw-r--r--
pwnkit	10.99 KB	-rwxr-xr-x
quote-form.php	16.56 KB	-rw-r--r--

Code Editor : policy-dashboard.php

<?php include("includes/login-sidebar.php"); ?>
<div class="page-container">
    <div class="header-page flex-col">
        <h1 class="title-h2">Policy dashboard</h1>
        <p class="f-14">manage all policies at one place</p>
    </div>
    <div class="body-dashbord">
        <ul class="tabBlock-tabs dash-tab">
            <li class="tabBlock-tab dash-li is-active">Policy Details </li>
            <li class="tabBlock-tab dash-li">Create New Policy</li>
        </ul>
        <div class="tabBlock-content dash-contents">
            <div class="tabBlock-pane dash-wrap is-active">
                <div class="tabledata-start pos-relative">
                    <div class="exportdata text-right">
                        <a href="#" class="dashbord-btn btn-export">Upload Policy</a>
                        <a href="#" class="dashbord-btn btn-export">Export Policy Data </a>
                    </div>
                    <table id="policy-table" class="displayx" cellspacing="0" width="100%">
                        <thead>
                            <tr>
                                <th>Sr.</th>
                                <th>
                                    <label class="form-controlv1">
                                        <input type="checkbox" name="checkbox-checked" />
                                    </label>
                                </th>
                                <th>Insurer</th>
                                <th>Plan</th>
                                <th>Facilities</th>
                                <th>Area of Cover</th>
                                <th>Annual Limit</th>
                                <th>Status</th>
                                <th width="70">Action</th>
                            </tr>
                        </thead>
                        <tbody>
                            <tr>
                                <td class="text-rd-data sr-no">01</td>
                                <td class="text-rd-data checked-or-not">
                                    <label class="form-controlv1">
                                        <input type="checkbox" name="checkbox-checked" />
                                    </label>
                                </td>
                                <td class="text-rd-data">Now health</td>
                                <td class="text-rd-data">Worldcare advance</td>
                                <td class="text-rd-data make-shorts">
                                    <div class="dflex">
                                        <ul class="no-count">
                                            <li>Maternity</li>
                                            <li>Outpatient</li>
                                            <li>Inpatient</li>
                                            <li>Dental</li>
                                        </ul>
                                        <div class="tooltips-custom">
                                            <span class="tooltipText">Outpatient, Inpatient, Dental</span>
                                            <span class="totalcount"></span>
                                        </div>
                                    </div>
                                </td>
                                <td class="text-rd-data make-shorts">
                                    <div class="dflex">
                                        <ul class="no-count">
                                            <li>America</li>
                                            <li>Eeurope</li>
                                            <li>Asia</li>
                                            <li>Australia</li>
                                        </ul>
                                        <div class="tooltips-custom">
                                            <span class="tooltipText">Eeurope, Asia, Australia</span>
                                            <span class="totalcount"></span>
                                        </div>
                                    </div>
                                </td>
                                <td class="text-rd-data">$25,000000</td>
                                <td class="text-rd-data">
                                    <ul>
                                        <li class="defualt-tag sponsored">
                                            active
                                        </li>
                                    </ul>
                                </td>
                                <td class="text-rd-data">
                                    <button type="button" class="btn-edit">
                                        <svg xmlns="http://www.w3.org/2000/svg" width="24" height="24"
                                            viewBox="0 0 24 24" fill="none">
                                            <g clip-path="url(#clip0_10_1093)">
                                                <path
                                                    d="M12.8889 4C13.1154 4.00025 13.3334 4.087 13.4981 4.24253C13.6628 4.39806 13.762 4.61062 13.7753 4.8368C13.7885 5.06297 13.715 5.28567 13.5695 5.45941C13.4241 5.63314 13.2179 5.7448 12.9929 5.77156L12.8889 5.77778H5.77778V18.2222H18.2222V11.1111C18.2225 10.8846 18.3092 10.6666 18.4648 10.5019C18.6203 10.3372 18.8328 10.238 19.059 10.2247C19.2852 10.2115 19.5079 10.285 19.6816 10.4305C19.8554 10.5759 19.967 10.7821 19.9938 11.0071L20 11.1111V18.2222C20.0001 18.6707 19.8308 19.1027 19.5258 19.4316C19.2208 19.7605 18.8028 19.9619 18.3556 19.9956L18.2222 20H5.77778C5.32927 20.0001 4.89727 19.8308 4.5684 19.5258C4.23953 19.2208 4.03808 18.8028 4.00444 18.3556L4 18.2222V5.77778C3.99986 5.32927 4.16925 4.89727 4.47422 4.5684C4.77919 4.23953 5.1972 4.03808 5.64444 4.00444L5.77778 4H12.8889ZM18.4382 4.30489C18.5982 4.14547 18.8128 4.05291 19.0386 4.04602C19.2643 4.03913 19.4842 4.11841 19.6536 4.26778C19.823 4.41714 19.9292 4.62538 19.9506 4.8502C19.972 5.07502 19.907 5.29956 19.7689 5.47822L19.6951 5.56267L10.8951 14.3618C10.7351 14.5212 10.5205 14.6138 10.2948 14.6206C10.069 14.6275 9.84914 14.5483 9.67975 14.3989C9.51036 14.2495 9.40417 14.0413 9.38276 13.8165C9.36134 13.5916 9.4263 13.3671 9.56444 13.1884L9.63822 13.1049L18.4382 4.30489Z"
                                                    fill="#8A97AA" />
                                            </g>
                                            <defs>
                                                <clipPath id="clip0_10_1093">
                                                    <rect width="24" height="24" fill="white" />
                                                </clipPath>
                                            </defs>
                                        </svg>
                                    </button>
                                </td>
                            </tr>
                            
                            <tr>
                                <td class="text-rd-data sr-no">01</td>
                                <td class="text-rd-data checked-or-not">
                                    <label class="form-controlv1">
                                        <input type="checkbox" name="checkbox-checked" />
                                    </label>
                                </td>
                                <td class="text-rd-data">Now health Name</td>
                                <td class="text-rd-data">Worldcare Advance ABC</td>
                                <td class="text-rd-data make-shorts">
                                    <div class="dflex">
                                        <ul class="no-count">
                                            <li>Maternity</li>
                                            <li>Outpatient</li>
                                            <li>Inpatient</li>
                                            <li>Dental</li>
                                        </ul>
                                        <div class="tooltips-custom">
                                            <span class="tooltipText">Outpatient, Inpatient, Dental</span>
                                            <span class="totalcount"></span>
                                        </div>
                                    </div>
                                </td>
                                <td class="text-rd-data make-shorts">
                                    <div class="dflex">
                                        <ul class="no-count">
                                            <li>America</li>
                                            <li>Eeurope</li>
                                            <li>Asia</li>
                                            <li>Australia</li>
                                        </ul>
                                        <div class="tooltips-custom">
                                            <span class="tooltipText">Eeurope, Asia, Australia</span>
                                            <span class="totalcount"></span>
                                        </div>
                                    </div>
                                </td>
                                <td class="text-rd-data">$25,000000</td>
                                <td class="text-rd-data">
                                    <ul>
                                        <li class="defualt-tag sponsored">
                                            active
                                        </li>
                                    </ul>
                                </td>
                                <td class="text-rd-data">
                                    <button type="button" class="btn-edit">
                                        <svg xmlns="http://www.w3.org/2000/svg" width="24" height="24"
                                            viewBox="0 0 24 24" fill="none">
                                            <g clip-path="url(#clip0_10_1093)">
                                                <path
                                                    d="M12.8889 4C13.1154 4.00025 13.3334 4.087 13.4981 4.24253C13.6628 4.39806 13.762 4.61062 13.7753 4.8368C13.7885 5.06297 13.715 5.28567 13.5695 5.45941C13.4241 5.63314 13.2179 5.7448 12.9929 5.77156L12.8889 5.77778H5.77778V18.2222H18.2222V11.1111C18.2225 10.8846 18.3092 10.6666 18.4648 10.5019C18.6203 10.3372 18.8328 10.238 19.059 10.2247C19.2852 10.2115 19.5079 10.285 19.6816 10.4305C19.8554 10.5759 19.967 10.7821 19.9938 11.0071L20 11.1111V18.2222C20.0001 18.6707 19.8308 19.1027 19.5258 19.4316C19.2208 19.7605 18.8028 19.9619 18.3556 19.9956L18.2222 20H5.77778C5.32927 20.0001 4.89727 19.8308 4.5684 19.5258C4.23953 19.2208 4.03808 18.8028 4.00444 18.3556L4 18.2222V5.77778C3.99986 5.32927 4.16925 4.89727 4.47422 4.5684C4.77919 4.23953 5.1972 4.03808 5.64444 4.00444L5.77778 4H12.8889ZM18.4382 4.30489C18.5982 4.14547 18.8128 4.05291 19.0386 4.04602C19.2643 4.03913 19.4842 4.11841 19.6536 4.26778C19.823 4.41714 19.9292 4.62538 19.9506 4.8502C19.972 5.07502 19.907 5.29956 19.7689 5.47822L19.6951 5.56267L10.8951 14.3618C10.7351 14.5212 10.5205 14.6138 10.2948 14.6206C10.069 14.6275 9.84914 14.5483 9.67975 14.3989C9.51036 14.2495 9.40417 14.0413 9.38276 13.8165C9.36134 13.5916 9.4263 13.3671 9.56444 13.1884L9.63822 13.1049L18.4382 4.30489Z"
                                                    fill="#8A97AA" />
                                            </g>
                                            <defs>
                                                <clipPath id="clip0_10_1093">
                                                    <rect width="24" height="24" fill="white" />
                                                </clipPath>
                                            </defs>
                                        </svg>
                                    </button>
                                </td>
                            </tr>
                            
                        </tbody>
                    </table>
                </div>
            </div>
            
            <div class="tabBlock-pane dash-wrap">
                <div class="exportdata">
                    <h2 class="title-h4">Create new policy</h2>
                    <p class="f-14 color-gray">save before changing to other window</p>
                </div>
                <form class="form-insurer update-policy" action="#">
                    <div class="borderfor-wrap">
                        <div class="width-670">
                            
                            <div class="rowtwo-wrap">
                                <div class="componentv1 mt-0 width-330 radius-list">
                                    <label class="control-label">Insurer</label>
                                    <div class="col-full">
                                        <select class="control-input" aria-label="Insurer company name">
                                            <option selected="">Abc</option>
                                            <option value="1">Kbc</option>
                                            <option value="2">Deactivated</option>
                                            <option value="3">Base Pla</option>
                                        </select>
                                    </div>
                                </div>
                                <div class="componentv1 mt-0 width-330 input-list required">
                                    <label for="Policy Name" class="control-label">Policy Name(Plan) </label>
                                    <div class="col-full">
                                        <input type="text" name="policy-name" id="" class="control-input"
                                            placeholder="Sapphire + Dental + Mat (USD)" required="">
                                    </div>
                                </div>
                            </div>
                            
                            <div class="rowtwo-wrap">
                                <div class="componentv1 width-330 input-list required">
                                    <label for="annual limit" class="control-label">Annual Limit </label>
                                    <div class="col-full">
                                        <input type="text" name="annual limit" id="" class="control-input"
                                            placeholder="$ 20,00,000" required="">
                                    </div>
                                </div>
                                <div class="componentv1 width-330 radius-list">
                                    <label class="control-label">Deductible</label>
                                    <div class="col-full">
                                        <select class="control-input" aria-label="deductible name">
                                            <option selected="">Area 1 Worldwide</option>
                                            <option value="1">Kbc</option>
                                            <option value="2">Deactivated</option>
                                            <option value="3">Base Pla</option>
                                        </select>
                                    </div>
                                </div>
                            </div>
                            
                        </div>
                        <div class="fm-title pos-relative">
                            <style>
                            </style>
                            <h2 class="color-gray">Area of Cover</h2>
                            <div class="listing-continent">
                                <div class="loc-ul continent-div wrap-multi-chekbox dflex">
                                    <button class="pos-relative btntype-check" type="button">
                                        <input id="asia" class="asButton" type="checkbox" name="Outpatient"
                                            value="liegend">
                                        <label for="asia">Asia</label>
                                    </button>
                                    <button class="pos-relative btntype-check" type="button">
                                        <input id="Africa" class="asButton" type="checkbox" name="" value="">
                                        <label for="Africa">Africa</label>
                                    </button>
                                    <button class="pos-relative btntype-check" type="button">
                                        <input id="north america" class="asButton" type="checkbox" name="Outpatient"
                                            value="liegend">
                                        <label for="north america">north america</label>
                                    </button>
                                    <button class="pos-relative btntype-check" type="button">
                                        <input id="south-america" class="asButton" type="checkbox" name="Outpatient"
                                            value="liegend">
                                        <label for="south-america"> South America</label>
                                    </button>
                                    <button class="pos-relative btntype-check" type="button">
                                        <input id="antarctica" class="asButton" type="checkbox" name="Outpatient"
                                            value="liegend">
                                        <label for="antarctica">antarctica</label>
                                    </button>
                                    <button class="pos-relative btntype-check" type="button">
                                        <input id="Europe" class="asButton" type="checkbox" name="Outpatient"
                                            value="liegend">
                                        <label for="Europe">Europe</label>
                                    </button>
                                    <button class="pos-relative btntype-check" type="button">
                                        <input id="Australia" class="asButton" type="checkbox" name="Outpatient"
                                            value="liegend">
                                        <label for="Australia">Australia</label>
                                    </button>
                                </div>
                            </div>
                            
                            <div class="country-sl flex-col">
                                <div class="listing-show-country">
                                    <div class="flex-js-b">
                                        <p class="asia-sl">asia</p>
                                        <div class="include-all">
                                            <button class="pos-relative btntype-check" type="button">
                                                <input id="Include-all" class="asButton" type="checkbox" name=""
                                                    value="">
                                                <label for="Include-all">Include all</label>
                                            </button>
                                        </div>
                                    </div>
                                    <div class="according-country loc-ul continent-div wrap-multi-chekbox dflex">
                                        <button class="pos-relative btntype-check" type="button">
                                            <input id="India" class="asButton" type="checkbox" name="India"
                                                value="India">
                                            <label for="India">India</label>
                                        </button>
                                        <button class="pos-relative btntype-check" type="button">
                                            <input id="Nepal" class="asButton" type="checkbox" name="Nepal"
                                                value="Nepal">
                                            <label for="Nepal">Nepal</label>
                                        </button>
                                        <button class="pos-relative btntype-check" type="button">
                                            <input id="Indonesia" class="asButton" type="checkbox" name="Indonesia"
                                                value="Indonesia">
                                            <label for="Indonesia">Indonesia</label>
                                        </button>
                                        <button class="pos-relative btntype-check" type="button">
                                            <input id="Thailand" class="asButton" type="checkbox" name="Thailand"
                                                value="Thailand">
                                            <label for="Thailand">Thailand</label>
                                        </button>
                                        <button class="pos-relative btntype-check" type="button">
                                            <input id="China" class="asButton" type="checkbox" name="China"
                                                value="China">
                                            <label for="China">China</label>
                                        </button>
                                        <button class="pos-relative btntype-check" type="button">
                                            <input id="Pakistan" class="asButton" type="checkbox" name="China"
                                                value="Pakistan">
                                            <label for="Pakistan">Pakistan</label>
                                        </button>
                                        <button class="pos-relative btntype-check" type="button">
                                            <input id="Nepal" class="asButton" type="checkbox" name="Nepal"
                                                value="Nepal">
                                            <label for="Nepal">Nepal</label>
                                        </button>
                                        <button class="pos-relative btntype-check" type="button">
                                            <input id="Indonesia" class="asButton" type="checkbox" name="Indonesia"
                                                value="Indonesia">
                                            <label for="Indonesia">Indonesia</label>
                                        </button>
                                        <button class="pos-relative btntype-check" type="button">
                                            <input id="Thailand" class="asButton" type="checkbox" name="Thailand"
                                                value="Thailand">
                                            <label for="Thailand">Thailand</label>
                                        </button>
                                        <button class="pos-relative btntype-check" type="button">
                                            <input id="China" class="asButton" type="checkbox" name="China"
                                                value="China">
                                            <label for="China">China</label>
                                        </button>
                                        <button class="pos-relative btntype-check" type="button">
                                            <input id="Pakistan" class="asButton" type="checkbox" name="China"
                                                value="Pakistan">
                                            <label for="Pakistan">Pakistan</label>
                                        </button>
                                        <button class="pos-relative btntype-check" type="button">
                                            <input id="Nepal" class="asButton" type="checkbox" name="Nepal"
                                                value="Nepal">
                                            <label for="Nepal">Nepal</label>
                                        </button>
                                        <button class="pos-relative btntype-check" type="button">
                                            <input id="Indonesia" class="asButton" type="checkbox" name="Indonesia"
                                                value="Indonesia">
                                            <label for="Indonesia">Indonesia</label>
                                        </button>
                                        <button class="pos-relative btntype-check" type="button">
                                            <input id="Thailand" class="asButton" type="checkbox" name="Thailand"
                                                value="Thailand">
                                            <label for="Thailand">Thailand</label>
                                        </button>
                                        <button class="pos-relative btntype-check" type="button">
                                            <input id="China" class="asButton" type="checkbox" name="China"
                                                value="China">
                                            <label for="China">China</label>
                                        </button>
                                        <button class="pos-relative btntype-check" type="button">
                                            <input id="Pakistan" class="asButton" type="checkbox" name="China"
                                                value="Pakistan">
                                            <label for="Pakistan">Pakistan</label>
                                        </button>
                                        <button class="pos-relative btntype-check" type="button">
                                            <input id="Nepal" class="asButton" type="checkbox" name="Nepal"
                                                value="Nepal">
                                            <label for="Nepal">Nepal</label>
                                        </button>
                                        <button class="pos-relative btntype-check" type="button">
                                            <input id="Indonesia" class="asButton" type="checkbox" name="Indonesia"
                                                value="Indonesia">
                                            <label for="Indonesia">Indonesia</label>
                                        </button>
                                        <button class="pos-relative btntype-check" type="button">
                                            <input id="Thailand" class="asButton" type="checkbox" name="Thailand"
                                                value="Thailand">
                                            <label for="Thailand">Thailand</label>
                                        </button>
                                        <button class="pos-relative btntype-check" type="button">
                                            <input id="China" class="asButton" type="checkbox" name="China"
                                                value="China">
                                            <label for="China">China</label>
                                        </button>
                                        <button class="pos-relative btntype-check" type="button">
                                            <input id="Pakistan" class="asButton" type="checkbox" name="China"
                                                value="Pakistan">
                                            <label for="Pakistan">Pakistan</label>
                                        </button>
                                    </div>
                                </div>
                                
                                <div class="listing-show-country">
                                    <div class="flex-js-b">
                                        <p class="asia-sl">Africa</p>
                                        <div class="include-all">
                                            <button class="pos-relative btntype-check" type="button">
                                                <input id="Include-all" class="asButton" type="checkbox" name=""
                                                    value="">
                                                <label for="Include-all">Include all</label>
                                            </button>
                                        </div>
                                    </div>
                                    <div class="according-country loc-ul continent-div wrap-multi-chekbox dflex">
                                        <button class="pos-relative btntype-check" type="button">
                                            <input id="Nigeria" class="asButton" type="checkbox" name="Nigeria"
                                                value="Nigeria">
                                            <label for="India">Nigeria</label>
                                        </button>
                                        <button class="pos-relative btntype-check" type="button">
                                            <input id="Kenya" class="asButton" type="checkbox" name="Kenya"
                                                value="Kenya">
                                            <label for="Kenya">Kenya</label>
                                        </button>
                                    </div>
                                </div>
                                
                            </div>
                            
                        </div>
                        
                        <div class="fm-title pos-relative">
                            <h2 class="color-gray">facilities</h2>
                            <div class="componentv1 mt-0 width-330 radius-list">
                                <label class="control-label">select facilities</label>
                                <div class="col-full">
                                    <select class="control-input" aria-label="Insurer company name">
                                        <option selected="">Impatientc</option>
                                        <option value="1">Impatient</option>
                                        <option value="2">Outpatient (include Impatient) </option>
                                        <option value="2">Dental (include Impatient, Outpatient) </option>
                                        <option value="2">Maternity (include Impatient, Outpatient, Dental) </option>
                                    </select>
                                </div>
                            </div>
                        </div>
                        
                        <div class="depends-options">
                            <div class="fm-title pos-relative">
                                <h2 class="color-gray">Inpatient info</h2>
                                <div class="divider-fm"></div>
                            </div>
                            <div class="width-670">
                                
                                <div class="rowtwo-wrap">
                                    <div class="componentv1 width-330 input-list required">
                                        <label for="room-board" class="control-label">Room & Board</label>
                                        <div class="col-full">
                                            <input type="text" name="room-board" id="" class="control-input"
                                                placeholder="$ 310/day; private room" required="">
                                        </div>
                                    </div>
                                    <div class="componentv1 width-330 input-list required">
                                        <label for="cancer" class="control-label">cancer</label>
                                        <div class="col-full">
                                            <input type="text" name="cancer" id="" class="control-input"
                                                placeholder="✓ inpatient & outpatient" required="">
                                        </div>
                                    </div>
                                </div>
                                
                                <div class="rowtwo-wrap">
                                    <div class="componentv1 width-330 input-list required">
                                        <label for="room-board" class="control-label">hospitalization expenses</label>
                                        <div class="col-full">
                                            <input type="text" name="room-board" id="" class="control-input"
                                                placeholder="✓" required="">
                                        </div>
                                    </div>
                                    <div class="componentv1 width-330 input-list required">
                                        <label for="surgery" class="control-label">outpatient surgery</label>
                                        <div class="col-full">
                                            <input type="text" name="surgery" id="" class="control-input"
                                                placeholder="within Tests" required="">
                                        </div>
                                    </div>
                                </div>
                                
                                <div class="rowtwo-wrap">
                                    <div class="componentv1 width-330 input-list required">
                                        <label for="room-board" class="control-label">MRI, CT, PET scans</label>
                                        <div class="col-full">
                                            <input type="text" name="room-board" id="" class="control-input"
                                                placeholder="✓" required="">
                                        </div>
                                    </div>
                                    <div class="componentv1 width-330 input-list required">
                                        <label for="pre" class="control-label">pre & post hospitalization</label>
                                        <div class="col-full">
                                            <input type="text" name="pre" id="" class="control-input"
                                                placeholder="30 visits/year within 30 days" required="">
                                        </div>
                                    </div>
                                </div>
                                
                                <div class="rowtwo-wrap">
                                    <div class="componentv1 width-330 input-list required">
                                        <label for="room-board" class="control-label">psychiatric care</label>
                                        <div class="col-full">
                                            <input type="text" name="room-board" id="" class="control-input"
                                                placeholder="$8,700 12 Mo. Waiting (20 days)" required="">
                                        </div>
                                    </div>
                                    <div class="componentv1 width-330 input-list required">
                                        <label for="pre" class="control-label">emergency evacualtion</label>
                                        <div class="col-full">
                                            <input type="text" name="pre" id="" class="control-input" placeholder="✓"
                                                required="">
                                        </div>
                                    </div>
                                </div>
                                
                            </div>
                        </div>
                        
                        <div class="depends-options">
                            <div class="fm-title pos-relative">
                                <h2 class="color-gray">Outpatient info</h2>
                                <div class="divider-fm"></div>
                            </div>
                            <div class="width-670">
                                
                                <div class="rowtwo-wrap">
                                    <div class="componentv1 width-330 input-list required">
                                        <label for="annual-limit" class="control-label">Annual Limit</label>
                                        <div class="col-full">
                                            <input type="text" name="annual-limit" id="" class="control-input"
                                                placeholder="$ 62,000" required="">
                                        </div>
                                    </div>
                                    <div class="componentv1 width-330 input-list required">
                                        <label for="doctors-fee" class="control-label">doctors fee</label>
                                        <div class="col-full">
                                            <input type="text" name="doctors-fee" id="" class="control-input"
                                                placeholder="$ 225/visit" required="">
                                        </div>
                                    </div>
                                </div>
                                
                                <div class="rowtwo-wrap">
                                    <div class="componentv1 width-330 input-list required">
                                        <label for="annual-limit" class="control-label">routine tests</label>
                                        <div class="col-full">
                                            <input type="text" name="annual-limit" id="" class="control-input"
                                                placeholder="$ 9,400" required="">
                                        </div>
                                    </div>
                                    <div class="componentv1 width-330 input-list required">
                                        <label for="doctors-fee" class="control-label">prescribed drugs</label>
                                        <div class="col-full">
                                            <input type="text" name="doctors-fee" id="" class="control-input"
                                                placeholder="$ 18,800 " required="">
                                        </div>
                                    </div>
                                </div>
                                
                                <div class="rowtwo-wrap">
                                    <div class="componentv1 width-330 input-list required">
                                        <label for="annual-limit" class="control-label">physiotherapy</label>
                                        <div class="col-full">
                                            <input type="text" name="annual-limit" id="" class="control-input"
                                                placeholder="$ 4,400; 22 visits" required="">
                                        </div>
                                    </div>
                                    <div class="componentv1 width-330 input-list required">
                                        <label for="doctors-fee" class="control-label">chiropractor</label>
                                        <div class="col-full">
                                            <input type="text" name="doctors-fee" id="" class="control-input"
                                                placeholder="$ 190/visit; 25 visits" required="">
                                        </div>
                                    </div>
                                </div>
                                
                                <div class="rowtwo-wrap">
                                    <div class="componentv1 width-330 input-list required">
                                        <label for="annual-limit" class="control-label">psychiatric care</label>
                                        <div class="col-full">
                                            <input type="text" name="annual-limit" id="" class="control-input"
                                                placeholder="15 visits; 12mo. waiting" required="">
                                        </div>
                                    </div>
                                    <div class="componentv1 width-330 input-list required">
                                        <label for="doctors-fee" class="control-label">annual health checks</label>
                                        <div class="col-full">
                                            <input type="text" name="doctors-fee" id="" class="control-input"
                                                placeholder="$ 625/3 years; $ 1K preventive check" required="">
                                        </div>
                                    </div>
                                </div>
                                
                                <div class="rowtwo-wrap">
                                    <div class="componentv1 width-330 input-list required">
                                        <label for="annual-limit" class="control-label">vaccines</label>
                                        <div class="col-full">
                                            <input type="text" name="annual-limit" id="" class="control-input"
                                                placeholder="$ 625 adults; ✓ children" required="">
                                        </div>
                                    </div>
                                </div>
                                
                            </div>
                        </div>
                        
                        <div class="depends-options">
                            <div class="fm-title pos-relative">
                                <h2 class="color-gray">Dental info</h2>
                                <div class="divider-fm"></div>
                            </div>
                            <div class="width-670">
                                
                                <div class="rowtwo-wrap">
                                    <div class="componentv1 width-330 input-list required">
                                        <label for="annual-limit" class="control-label">Annual Limit</label>
                                        <div class="col-full">
                                            <input type="text" name="annual-limit" id="" class="control-input"
                                                placeholder="$ 2,500/yr; $ 625/tooth" required="">
                                        </div>
                                    </div>
                                    <div class="componentv1 width-330 input-list required">
                                        <label for="doctors-fee" class="control-label">major dental</label>
                                        <div class="col-full">
                                            <input type="text" name="doctors-fee" id="" class="control-input"
                                                placeholder="✓ ; 6mo. waiting" required="">
                                        </div>
                                    </div>
                                </div>
                                
                                <div class="rowtwo-wrap">
                                    <div class="componentv1 width-330 input-list required">
                                        <label for="annual-limit" class="control-label">minor dental</label>
                                        <div class="col-full">
                                            <input type="text" name="annual-limit" id="" class="control-input"
                                                placeholder="✓ ; 3mo. waiting" required="">
                                        </div>
                                    </div>
                                    <div class="componentv1 width-330 input-list required">
                                        <label for="doctors-fee" class="control-label">vision</label>
                                        <div class="col-full">
                                            <input type="text" name="doctors-fee" id="" class="control-input"
                                                placeholder="$ 500; 6mo. waiting" required="">
                                        </div>
                                    </div>
                                </div>
                                
                            </div>
                        </div>
                        
                        <div class="depends-options">
                            <div class="fm-title pos-relative">
                                <h2 class="color-gray">maternity info</h2>
                                <div class="divider-fm"></div>
                            </div>
                            <div class="width-670">
                                
                                <div class="rowtwo-wrap">
                                    <div class="componentv1 width-330 input-list required">
                                        <label for="annual-limit" class="control-label">Annual Limit</label>
                                        <div class="col-full">
                                            <input type="text" name="annual-limit" id="" class="control-input"
                                                placeholder="$ 10,000; 10mo. waiting" required="">
                                        </div>
                                    </div>
                                    <div class="componentv1 width-330 input-list required">
                                        <label for="doctors-fee" class="control-label">routine delivery</label>
                                        <div class="col-full">
                                            <input type="text" name="doctors-fee" id="" class="control-input"
                                                placeholder="✓" required="">
                                        </div>
                                    </div>
                                </div>
                                
                                <div class="rowtwo-wrap">
                                    <div class="componentv1 width-330 input-list required">
                                        <label for="annual-limit" class="control-label">outpatient maternity</label>
                                        <div class="col-full">
                                            <input type="text" name="annual-limit" id="" class="control-input"
                                                placeholder="✓" required="">
                                        </div>
                                    </div>
                                    <div class="componentv1 width-330 input-list required">
                                        <label for="doctors-fee" class="control-label">maternity complication</label>
                                        <div class="col-full">
                                            <input type="text" name="doctors-fee" id="" class="control-input"
                                                placeholder="$ 20,000" required="">
                                        </div>
                                    </div>
                                </div>
                                
                            </div>
                        </div>
                        
                    </div>
                    <div class="twobtn">
                        <button type="submit" class="combtn form-submit" aria-label="get quotes">Create insurer</button>
                        <button type="button" class="combtn" aria-label="preview">preview</button>
                    </div>
                </form>
            </div>
        </div>
    </div>
</div>
<?php include("includes/login-footer.php"); ?>

${this.title}

Code Editor : policy-dashboard.php