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Code Editor : quote-form.php
<?php include("includes/header.php"); ?> <section class="quote-fm"> <div class="custom-container"> <form id="multiStepForm" class="pos-relative"> <!-- progressbar --> <!-- <ul class="pg-class" id="progressbar"> <li class="active"><span class="dotts"></span></li> <li><span class="dotts"></span></li> <li><span class="dotts"></span></li> <li><span class="dotts"></span></li> </ul> --> <div class="flex-js-b "> <div class="wraps-steps"> <div class="step stepv1 active"> <div class="mak-space flex-col justify-spacebt"> <div class="wrap-div"> <p class="indicator color-7c ">Step <span>1</span> of 4</p> <h2 class="title32">Let’s find best Insurance plans for your needs.</h2> <div class="fm-list"> <div class="divfm-width"> <label for="Your name" class="form-label">Your Name</label> <input type="text" class="control-v1" aria-describedby="Your name"> </div> <!-- 1 --> <div class="divfm-width"> <label for="Area of cover" class="form-label">Area of cover (Residence country)</label> <select class="control-v1" aria-label="Area of cover"> <option selected>Thailand</option> <option value="1">India</option> <option value="2">USA</option> <option value="3">UAE</option> </select> </div> <!-- 1 --> <div class="divfm-width"> <label for="Your Nationality" class="form-label">Your Nationality</label> <select class="control-v1" aria-label="Your Nationality"> <option selected>Thai</option> <option value="1">India</option> <option value="2">USA</option> <option value="3">UAE</option> </select> </div> <!-- 1 --> </div> </div> <div class="flex-js-b align-end "> <div class="btn-continue"> <button type="button" class="btn-next outline-btn">Next</button> </div> <!-- <p class="f-14 form-label">Select an option to move forward</p> --> </div> </div> </div> <!--step 2 --> <div class="step stepv2"> <div class="mak-space flex-col justify-spacebt"> <div class="wrap-div"> <p class="indicator color-7c">Step <span>2</span> of 4</p> <h2 class="title32">Who would you like to cover in Insurance plan?</h2> <div class="fm-list"> <div class="divfm-width"> <div class="cst-radio"> <input type="radio" id="myself" name="radio-group" checked> <label for="myself">myself</label> </div> <div class="cst-radio"> <input type="radio" id="my-wife" name="radio-group"> <label for="my-wife">me & my wife</label> </div> <div class="cst-radio"> <input type="radio" id="my-family" name="radio-group"> <label for="my-family">my family</label> </div> <div class="cst-radio"> <input type="radio" id="my-kid" name="radio-group"> <label for="my-kid">me & my kid(s)</label> </div> </div> </div> </div> <div class="flex-js-b align-end "> <div class="btn-continue"> <button type="button" class="btn-next outline-btn">Next</button> <button type="button" class="btn-prev outline-btn">Back</button> </div> <!-- <p class="f-14 form-label">Select an option to move forward</p> --> </div> </div> </div> <!--step 3 --> <div class="step stepv3"> <div class="mak-space flex-col justify-spacebt"> <div class="wrap-div"> <p class="indicator color-7c">Step <span>3</span> of 4</p> <h2 class="title32">Insurance should cover...</h2> <div class="fm-list"> <div class="divfm-width"> <div class="cst-radio"> <input type="checkbox" id="check1" name="checkbox-group" checked> <label for="check1">inpatient</label> </div> <div class="cst-radio"> <input type="checkbox" id="check2" name="checkbox-group"> <label for="check2">outpatient</label> </div> <div class="cst-radio"> <input type="checkbox" id="check3" name="checkbox-group"> <label for="check3">dental</label> </div> <div class="cst-radio"> <input type="checkbox" id="check4" name="checkbox-group"> <label for="check4">maternity</label> </div> </div> </div> </div> <div class="flex-js-b align-end "> <div class="btn-continue"> <button type="button" class="btn-next outline-btn">Next</button> <button type="button" class="btn-prev outline-btn">Back</button> </div> <!-- <p class="f-14 form-label">Select an option to move forward</p> --> </div> </div> </div> <!--step 4 --> <div class="step stepv4"> <div class="mak-space flex-col justify-spacebt"> <div class="wrap-div"> <p class="indicator color-7c">Step <span>4</span> of 4</p> <h2 class="title32">We are Good to go after this.</h2> <div class="twoleft"> <div class="left-data fm-list"> <div class="flex-js-b flex-acenter"> <p class="color-7c">My age is</p> <p class="color-7c"><input type="text" class="control-v1" aria-describedby="My Age is"> </p> </div> <div class="flex-js-b flex-acenter"> <p class="color-7c">& My Better Half’s age is</p> <p class="color-7c"><input type="text" class="control-v1" aria-describedby="My Age is"> </p> </div> </div> <div class="right-data"> <button type="button" class="addchild mb-16 outlineicons"> <svg xmlns="http://www.w3.org/2000/svg" width="20" height="20" viewBox="0 0 24 24" fill="none"> <path d="M21 12C21 12.1989 20.921 12.3897 20.7803 12.5303C20.6397 12.671 20.4489 12.75 20.25 12.75H12.75V20.25C12.75 20.4489 12.671 20.6397 12.5303 20.7803C12.3897 20.921 12.1989 21 12 21C11.8011 21 11.6103 20.921 11.4697 20.7803C11.329 20.6397 11.25 20.4489 11.25 20.25V12.75H3.75C3.55109 12.75 3.36032 12.671 3.21967 12.5303C3.07902 12.3897 3 12.1989 3 12C3 11.8011 3.07902 11.6103 3.21967 11.4697C3.36032 11.329 3.55109 11.25 3.75 11.25H11.25V3.75C11.25 3.55109 11.329 3.36032 11.4697 3.21967C11.6103 3.07902 11.8011 3 12 3C12.1989 3 12.3897 3.07902 12.5303 3.21967C12.671 3.36032 12.75 3.55109 12.75 3.75V11.25H20.25C20.4489 11.25 20.6397 11.329 20.7803 11.4697C20.921 11.6103 21 11.8011 21 12Z" fill="#49A4F3" stroke="#49A4F3" /> </svg> Add Child</button> <div class="rows-container max-560"> </div> <p class="color-7c limit-message hidden">limit reached, you can enquire for more members</p> </div> </div> </div> <div class="flex-js-b align-end "> <div class="btn-continue"> <button type="button" class="btn-next outline-btn">generate quotes</button> <button type="button" class="btn-prev outline-btn">Back</button> </div> <!-- <p class="f-14 form-label">Select an option to move forward</p> --> </div> </div> </div> <!-- end fm --> </div><!-- wrap steps --> <div class="verify-data flex-col card-componets"> <h2 class="title-h4 opt-75">Details provided <span class="f-14 color-gray">(use to cross check)</span></h2> <div class="flex-acenter"> <label for="name" class="hzlabel width-41">Name</label> <div class="input-hz"> <input type="text" class="form-control-xs" id="" placeholder="" value="Mo Buglow"> </div> </div> <!--1--> <div class="flex-acenter"> <label for="residence" class="hzlabel width-41">Residence</label> <div class="input-hz"> <input type="text" class="form-control-xs" id="" placeholder="" value="Thailand"> </div> </div> <!--1--> <div class="flex-acenter"> <label for="nationality" class="hzlabel width-41">Nationality</label> <div class="input-hz"> <input type="text" class="form-control-xs" id="" placeholder="" value="Thailand"> </div> </div> <!--1--> <div class="flex-acenter"> <label for="Insurance Plan for" class="hzlabel width-41">Insurance Plan for</label> <div class="input-hz"> <input type="text" class="form-control-xs" id="" placeholder="" value="Thailand"> </div> </div> <!--1--> <div class="flex-acenter"> <label for="ages" class="hzlabel width-41">Your age</label> <div class="input-hz"> <input type="number" class="form-control-xs" id="" placeholder="" value=""> </div> </div> <!--1--> <div class="flex-acenter"> <label for="residence" class="hzlabel width-41">Your Better Half’s age</label> <div class="input-hz"> <input type="text" class="form-control-xs" id="" placeholder="" value="Thailand"> </div> </div> <!--1--> <div class="flex-acenter"> <label for="residence" class="hzlabel width-41">Child’s age</label> <div class="input-hz child-box flex-js-b"> <input type="text" class="form-control-xs" id="" placeholder="" value=""> <input type="text" class="form-control-xs" id="" placeholder="" value=""> <input type="text" class="form-control-xs" id="" placeholder="" value=""> </div> </div> <!--1--> <div class="row-chekbox "> <label for="Insurance Covers" class="hzlabel width-41">Insurance Covers</label> <div class="wrap-multi-chekbox dflex"> <button class="pos-relative btntype-check" type="button"> <input id="Inpatient" class="asButton" type="checkbox" name="" value="" checked="checked"> <label for="Inpatient">Inpatient</label> </button> <button class="pos-relative btntype-check" type="button"> <input id="Outpatient" class="asButton" type="checkbox" name="Outpatient" value="liegend"> <label for="Outpatient">"Outpatient</label> </button> <button class="pos-relative btntype-check" type="button"> <input id="Dental" class="asButton" type="checkbox" name="meldungLageLiegend" value="liegend"> <label for="Dental">Dental</label> </button> <button class="pos-relative btntype-check" type="button"> <input id="Maternity" class="asButton" type="checkbox" name="meldungLageLiegend" value="liegend"> <label for="Maternity">Maternity</label> </button> </div> </div> </div> </div><!-- flex both --> </form> </div> </section> <?php include("includes/footer.php"); ?>
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