-
Notifications
You must be signed in to change notification settings - Fork 0
/
Copy pathmedical-form-yourself.html
executable file
·345 lines (325 loc) · 20.7 KB
/
medical-form-yourself.html
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
190
191
192
193
194
195
196
197
198
199
200
201
202
203
204
205
206
207
208
209
210
211
212
213
214
215
216
217
218
219
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
242
243
244
245
246
247
248
249
250
251
252
253
254
255
256
257
258
259
260
261
262
263
264
265
266
267
268
269
270
271
272
273
274
275
276
277
278
279
280
281
282
283
284
285
286
287
288
289
290
291
292
293
294
295
296
297
298
299
300
301
302
303
304
305
306
307
308
309
310
311
312
313
314
315
316
317
318
319
320
321
322
323
324
325
326
327
328
329
330
331
332
333
334
335
336
337
338
339
340
341
342
343
344
345
<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="utf-8">
<title>Insuredoo - Medical Self</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-self-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">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">
<label for="dob">Please select member's 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">
<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">
<label for="destination_country_zone_id">What's your Nationality?</label>
<div id="countries"></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="One More Step..." 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>