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medical-form-family.html
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<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="utf-8">
<title>Insuredoo - Medical Family</title>
<meta content="width=device-width, initial-scale=1.0" name="viewport">
<meta content="" name="keywords">
<meta content="" name="description">
<!-- Favicons -->
<link href="img/favicon.png" rel="icon">
<link href="img/apple-touch-icon.png" rel="apple-touch-icon">
<!-- Google Fonts -->
<link href="https://fonts.googleapis.com/css?family=Open+Sans:300,300i,400,400i,500,600,700,700i" rel="stylesheet">
<link href="https://fonts.googleapis.com/css?family=DM+Serif+Text&display=swap" rel="stylesheet">
<!-- Bootstrap CSS File -->
<link href="lib/bootstrap/css/bootstrap.min.css" rel="stylesheet">
<!-- Libraries CSS Files -->
<link href="lib/font-awesome/css/font-awesome.min.css" rel="stylesheet">
<link href="lib/animate/css/animate.min.css" rel="stylesheet">
<link href="lib/owlcarousel/css/owl.carousel.min.css" rel="stylesheet">
<link href="lib/fancybox/css/jquery.fancybox.min.css" rel="stylesheet" />
<link href="lib/form/css/select2.min.css" rel="stylesheet" />
<link href="lib/form/css/select2-bootstrap4.css" rel="stylesheet" />
<link href="lib/tooltip/css/tooltipster.bundle.min.css" rel="stylesheet" />
<link href="lib/tooltip/css/plugins/tooltipster/sideTip/themes/tooltipster-sideTip-light.min.css" rel="stylesheet" />
<!-- Main Stylesheet File -->
<link href="css/style.css" rel="stylesheet">
</head>
<body>
<a href="#" class="need-help-btn wow fadeInRight" data-wow-duration="1.4s"><i class="fa fa-envelope-o"></i> Need help?</a>
<!--==========================
Header
============================-->
<header id="header">
<div class="container-fluid">
<nav class="main-nav float-left d-none d-lg-block">
<ul>
<li><a href="about-insuredoo.html">About Us</a></li>
<li><a href="#products">Products</a></li>
<li><a href="#blog">Blog</a></li>
<li><a href="#claim">Claim</a></li>
<li class="d-lg-none"><a href="index.html">Insuredoo Jobs</a></li>
<li class="d-lg-none"><a href="index.html">English</a></li>
</ul>
</nav>
<!-- .main-nav -->
<div class="logo float-left d-lg-block">
<h1 class="text-center"><a href="index.html" class="scrollto"><img src="img/logo.png" alt="Insuredoo,The Easiest Way To Insure" class="img-fluid"></a></h1>
</div>
<div id="topbar" class="float-right d-lg-block">
<div class="right-menu">
<div class="right-menu-main-div login">
<p class="btn">Login </p>
<div class="login_box_container">
<div class="arrow-up"></div>
<div class="loginformholder">
<form action="index.html" method="post">
<p>
<label for="email_txt">Email</label>
<input type="email" placeholder="[email protected]" name="email_txt" id="email_txt" data-validation="required email" data-validation-error-msg="Please enter a valid email" />
</p>
<p>
<label for="password_txt">Password</label>
<input type="password" name="password_txt" id="password_txt" autocomplete="new-password" data-validation="required" data-validation-error-msg="Please enter your valid password" />
</p>
<input type="submit" value="Login" />
</form>
<div class="other_links"> <a href="#" class="forgot_my_password">Forgot my password</a> <a href="#" class="sign_up">Sign up</a> </div>
</div>
</div>
</div>
<div class="right-menu-main-div language d-none d-lg-block"><a href="index.html">E</a></div>
<div class="right-menu-main-div insuredoo-works-logo d-none d-lg-block"><a href="index.html"><img src="img/insuredoo-works-logo.png" alt="insuredoo jobs" class="img-fluid"></a></div>
</div>
</div>
</div>
</header>
<!-- #header -->
<!--==========================
Intro Section
============================-->
<main id="medical_insurance">
<!--==========================
Insurance Intro Section
============================-->
<section id="medical_insurance_intro" class="clearfix main_section">
<div class="container">
<header class="inner-page-section-header text-center">
<h2>GET MEDICAL INSURANCE QUOTE</h2>
</header>
</div>
</section>
<!-- #medical_insurance_intro -->
<!--==========================
Insurance Form Section
============================-->
<section id="medical_insurance_form" class="clearfix">
<div class="container">
<div class="row row-content">
<div class="col-lg-2 d-none d-lg-block"></div>
<div class="col-xl-8 col-lg-8 col-md-8 main-content">
<form action="medical-family-declaration.html" method="post" id="medical_form">
<div class="form-group mt-4 mb-4 clearfix">
<label for="full_name">What's your full name?</label>
<input type="text" class="form-control" name="full_name" id="full_name" placeholder="Full Name" data-validation="required" data-validation-allowing="positive" data-validation-error-msg="Please enter your full name">
</div>
<div class="form-group mt-4 mb-4 clearfix">
<label for="source_country_code">Which emirates is your visa issued from?</label>
<select name="city_id" id="city_id" data-validation="required">
<option value="">---</option>
<option value="1">Dubai</option>
<option value="2">Sharjah</option>
<option value="4">Ajman</option>
<option value="5">Ras Al Khaimah</option>
<option value="6">Fujairah</option>
<option value="7">Umm Al Quwain</option>
</select>
</div>
<div class="form-group mt-4 mb-4 clearfix">
<label for="phone_number">What's your phone number?</label>
<div class="input-group mb-2">
<div class="input-group-prepend">
<div class="input-group-text">+971</div>
</div>
<input type="text" class="form-control" name="phone_number" id="phone_number" placeholder="eg. 521234567" data-validation-length="9" data-validation="required length number" data-validation-allowing="positive" data-validation-error-msg="Please enter valid phone number in 9 digits">
</div>
</div>
<div class="form-group mt-4 mb-4 clearfix">
<label for="email">What's your email address?</label>
<input type="text" class="form-control" name="email" id="email" placeholder="eg. [email protected]" data-validation="required email" data-validation-error-msg="Please enter the valid email">
</div>
<div class="form-group mt-4 mb-4 clearfix">Is your salary more than AED 4,000 per month?
<div class="button-wrap">
<input class="hidden radio-label no_val" type="radio" name="salary_over_4k" id="salary_over_4k_no" value="no" checked="checked" />
<label class="button-label" for="salary_over_4k_no">
<p>No</p>
</label>
<input class="hidden radio-label yes_val" type="radio" name="salary_over_4k" id="salary_over_4k_yes" value="yes" />
<label class="button-label" for="salary_over_4k_yes">
<p>Yes</p>
</label>
</div>
</div>
<div class="form-group mt-4 mb-4 clearfix">Do you need insurance for yourself?
<div class="button-wrap">
<input class="hidden radio-label no_val order_members" type="radio" name="yourself_insurance" id="yourself_insurance_no" value="no" user-data="your_details_relative" user-data-action="hide" checked="checked" />
<label class="button-label" for="yourself_insurance_no">
<p>No</p>
</label>
<input class="hidden radio-label yes_val order_members" type="radio" name="yourself_insurance" id="yourself_insurance_yes" value="yes" user-data="your_details_relative" user-data-action="show" />
<label class="button-label" for="yourself_insurance_yes">
<p>Yes</p>
</label>
</div>
</div>
<div class="form-group mt-4 mb-4 clearfix">What type of cover are you looking for?
<div class="button-wrap">
<input class="hidden radio-label first_val" type="radio" name="viewEbp" id="viewEbp_minimum_legal_cover" value="I just want the minimum legal cover" />
<label class="button-label w-100 text-center" for="viewEbp_minimum_legal_cover">
<p>I just want the minimum legal cover</p>
</label>
<div class="w-100"></div>
<input class="hidden radio-label second_val" type="radio" name="viewEbp" id="viewEbp_more_than_minimum_cover" value="I want more than just the minimum cover" />
<label class="button-label w-100 text-center" for="viewEbp_more_than_minimum_cover">
<p>I want more than just the minimum cover</p>
</label>
<div class="w-100"></div>
<input class="hidden radio-label third_val" type="radio" name="viewEbp" id="viewEbp_show_everything" value="I'm not sure, just show me everything" checked="checked" />
<label class="button-label w-100 text-center" for="viewEbp_show_everything">
<p>I'm not sure, just show me everything</p>
</label>
</div>
</div>
<div class="form-group mt-4 mb-4 clearfix your_details_relative hidden">
<label for="dob">What's your date of birth?</label>
<input type="date" class="form-control" name="dob" id="dob" placeholder="YYYY-MM-DD" data-validation="required" data-validation-error-msg="Please enter your date of birth">
</div>
<div class="form-group mt-4 mb-4 clearfix your_details_relative hidden">
<label for="gender">What's your gender?</label>
<select name="gender" id="gender" data-validation="required" data-validation-error-msg="Please select your gender">
<option value="">---</option>
<option value="1">Male</option>
<option value="2">Female (Married)</option>
<option value="3">Female (Single)</option>
</select>
</div>
<div class="form-group mt-4 mb-4 clearfix your_details_relative hidden">
<label for="destination_country_zone_id">What's your Nationality?</label>
<div id="countries"></div>
</div>
<div id="people-container">
<div class="person_container" id="person_1" user-data="1">
<div class="row">
<div class="col">
<h3>Member <span>1</span>:</h3>
</div>
</div>
<div class="form-group mt-4 mb-4 clearfix">
<label for="members[1][relationship]">What's their relationship to you?</label>
<select name="members[1][relationship]" id="relationship_1" class="form-control select2-member" data-validation="required" data-validation-error-msg="Please select the relationship with your member">
<option value="">- Relationship -</option>
<option value="1">Child</option>
<option value="2">Spouse</option>
<option value="4">Parent</option>
</select>
</div>
<div class="form-group mt-4 mb-4 clearfix">
<label for="members[1][dob]">Please select member's date of birth?</label>
<input type="date" class="form-control dob-member" name="members[1][dob]" id="dob_1" placeholder="YYYY-MM-DD" data-validation="required" data-validation-error-msg="Please enter your member date of birth">
</div>
<div class="form-group mt-4 mb-4 clearfix">
<label for="members[1][gender]">What's their gender?</label><br>
<select name="members[1][gender]" id="gender_1" class="form-control select2-member" data-validation="required" data-validation-error-msg="Please select your member gender">
<option value="">---</option>
<option value="1">Male</option>
<option value="2">Female (Married)</option>
<option value="3">Female (Single)</option>
</select>
</div>
<div class="form-group mt-4 mb-4 clearfix">
<label for="members[1][nationality]">What's their nationality?</label><br>
<select name="members[1][nationality]" id="nationality_1" class="form-control select2-member nationalities" data-validation="required"></select>
</div>
<div class="form-group mt-4 mb-4 clearfix">Is their salary more than AED 4,000 per month?
<div class="button-wrap">
<input class="hidden radio-label no_val" type="radio" name="members[1][salary_over_4k]" id="salary_over_4k_no_1" value="no" checked="checked" />
<label class="button-label" for="salary_over_4k_no_1">
<p>No</p>
</label>
<input class="hidden radio-label yes_val" type="radio" name="members[1][salary_over_4k]" id="salary_over_4k_yes_1" value="yes" />
<label class="button-label" for="salary_over_4k_yes_1">
<p>Yes</p>
</label>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col add-new-person-container p-5"><a href="javascript:;" id="add-new-person"><i class="fa fa-user-plus"></i>
<p>Add another member</p>
</a></div>
</div>
<div class="form-group mt-4 mb-4 clearfix text-center">
<input type="submit" name="submit_insurance_data_form" id="submit_insurance_data_form" value="Continue" class="btn submit-btn">
</div>
</form>
</div>
<div class="col-lg-2 d-none d-lg-block"></div>
</div>
</div>
</section>
<!-- #medical_insurance_form -->
<!--==========================
Boxes Section
============================-->
<section id="motor_insurance_boxes" class="insurance_boxes">
<div class="container">
<div class="row flex-items-xs-middle flex-items-xs-center cards_container">
<div class="col-lg-2 d-none d-lg-block"></div>
<div class="col-xs-12 col-lg-4 col-md-6 wow fadeInLeft" data-wow-duration="1s">
<div class="card">
<div class="card-icon"><img src="img/insurance_form_page_icon_1.png" alt="card" class="img-fluid"></div>
<div class="card-block">
<h4 class="card-title"> SHOP AROUND </h4>
<p>You could save a lotwhen you search and compare with Insuredoo</p>
</div>
</div>
</div>
<div class="col-xs-12 col-lg-4 col-md-6 wow fadeInRight" data-wow-duration="1s">
<div class="card">
<div class="card-icon"><img src="img/insurance_form_page_icon_2.png" alt="card" class="img-fluid"></div>
<div class="card-block">
<h4 class="card-title"> PAY INSTALLMENTS </h4>
<p>you can pay yourinsurance in Installments with 0% interest</p>
</div>
</div>
</div>
<div class="col-lg-2 d-none d-lg-block"></div>
</div>
<!-- .cards_container -->
</div>
<!-- .container -->
</section>
<!-- #insurance_boxes -->
</main>
<!-- #medical_insurance -->
<!--==========================
Footer
============================-->
<footer id="footer" class="section-bg">
<div class="footer-top">
<div class="container">
<div class="row">
<div class="col-lg-12">
<div class="footer-newsletter">
<h2 class="pb-3">NEWSLETTER</h2>
<form action="index.html" method="post" class="newsletterForm">
<div class="form-group">
<input type="text" class="form-control" id="newsletter_name" name="newsletter_name" placeholder="Your Name" data-validation="required length alphanumeric" data-validation-length="3-16" data-validation-error-msg="Please enter your name" />
<div class="validation"></div>
</div>
<div class="form-group">
<input type="email" class="form-control" name="newsletter_email" id="newsletter_email" placeholder="Your Email" data-rule="email" data-validation="required email" data-validation-error-msg="Please enter a valid email" />
<div class="validation"></div>
</div>
<div id="sendmessage">Your message has been sent. Thank you!</div>
<input type="submit" class="form-control" value="Subscribe">
</form>
</div>
</div>
</div>
<div class="row">
<div class="col-lg-3 col-md-12 col-sm-12 col-xs-12">
<div class="footer-info"> <img src="img/logo_white.png" alt="Insuredoo,The Easiest Way To Insure" class="img-fluid">
<p>Why I say old chap that is sping lavatory chip shop gosh off his, smashing boot are you taking the piss posh loo brilliant matie boy young.!!</p>
</div>
<div class="social-links"> <a href="#" class="twitter"><i class="fa fa-twitter"></i></a> <a href="#" class="facebook"><i class="fa fa-facebook"></i></a> <a href="#" class="instagram"><i class="fa fa-instagram"></i></a> <a href="#" class="linkedin"><i class="fa fa-linkedin"></i></a> </div>
</div>
<div class="col-lg-3 col-md-6 col-sm-6 col-xs-12 footer_links_separator">
<div class="footer-links">
<ul>
<li><a href="motor.html">Motor Insurance</a></li>
<li><a href="home.html">Property Insurance</a></li>
<li><a href="index.html">Medical Insurance</a></li>
<li><a href="travel.html">Travel Insurance</a></li>
<li><a href="index.html">Mobile Insurance</a></li>
<li><a href="life.html">Life Insurance</a></li>
</ul>
</div>
</div>
<div class="col-lg-3 col-md-6 col-sm-6 col-xs-12 footer_links_separator">
<div class="footer-links">
<ul>
<li><a href="index.html">Pet Insurance</a></li>
<li><a href="index.html">GAP Insurance</a></li>
<li><a href="index.html">Blogs</a></li>
<li><a href="index.html">Claims</a></li>
<li><a href="index.html">About Insuredoo</a></li>
<li><a href="index.html">Privacy Policy</a></li>
<li><a href="index.html">Terms of Service</a></li>
<li><a href="index.html">Contact Us</a></li>
</ul>
</div>
</div>
<div class="col-lg-3 col-md-12 col-sm-12 col-xs-12">
<div class="speech-bubble">
<div class="owl-carousel twitter-carousel">
<div class="twitter-item"> BrandtWaldemar An awesome end to a great year. Congrats & happy 2020 <br>
<span>Unsplash<br>
January 04, 2020</span> </div>
<div class="twitter-item"> BrandtWaldemar An awesome end to a great year. Congrats & happy 2020 <br>
<span>Unsplash<br>
January 04, 2020</span> </div>
<div class="twitter-item"> BrandtWaldemar An awesome end to a great year. Congrats & happy 2020 <br>
<span>Unsplash<br>
January 04, 2020</span> </div>
<div class="twitter-item"> BrandtWaldemar An awesome end to a great year. Congrats & happy 2020 <br>
<span>Unsplash<br>
January 04, 2020</span> </div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="container">
<div class="copyright"> © Copyright 2020 Insuredoo </div>
</div>
</footer>
<!-- #footer -->
<a href="#" class="back-to-top"><i class="fa fa-chevron-up"></i></a>
<div id="preloader"></div>
<!-- JavaScript Libraries -->
<script src="lib/jquery/js/jquery.min.js"></script>
<script src="lib/jquery/js/jquery-migrate.min.js"></script>
<script src="lib/bootstrap/js/bootstrap.bundle.min.js"></script>
<script src="lib/easing/js/easing.min.js"></script>
<script src="lib/mobile-nav/js/mobile-nav.js"></script>
<script src="lib/wow/js/wow.min.js"></script>
<script src="lib/owlcarousel/js/owl.carousel.min.js"></script>
<script src="lib/fancybox/js/jquery.fancybox.min.js"></script>
<script src="lib/validation/js/jquery.form-validator.min.js"></script>
<script src="lib/form/js/select2.min.js"></script>
<script src="lib/tooltip/js/tooltipster.bundle.min.js"></script>
<script src="lib/country-selector/js/jquery.countrySelector.js"></script>
<!-- Template Main Javascript File -->
<script src="js/main.js"></script>
</body>
</html>