rakskci16

<p><label>Type of Insurance<span>*</span></label>[select* typeofinsurance id:typeofinsurance class:typeofinsurance "Individual/Dependent" "Group Medical"]</p>
[group group-medicalgroup]
<div class="row">
<div class="col-md-6 col-sm-6 col-xs-12 col-lg-6">
<p><label>Name<span>*</span></label>[text* contact_name id:contact_name class:contact_name_class]</p>
</div>
<div class="col-md-6 col-sm-6 col-xs-12 col-lg-6">
<p><label>Email<span>*</span></label>[email* contact_email id:contact_email class:contact_email]</p>
</div>
</div>
<div class="row">
<div class="col-md-6 col-sm-6 col-xs-12 col-lg-6">
<p><label>Mobile Number<span>*</span></label>[tel* contact_tel id:contact_tel class:contact_name_tel]</p>
</div>
<div class="col-md-6 col-sm-6 col-xs-12 col-lg-6">
<p><label>Company Name<span>*</span></label>
[text* company_name id:company_name class:company_name_class]</p>
</div>
</div>
<div class="row">
<div class="col-md-12 col-sm-12 col-xs-12 col-lg-12">
<p>Please download this form and fill the details
<a href="http://ms.kci-fms.com/download/Group%20Medical%20Census%20List.xlsx">Group Medical Census List Form</a></p>
<p>Please upload the Filled Census List Form provide above
[file* uploadFile filetypes:txt]</p>
</div>
</div>
[/group]
[group group-individual]<h2>Sponsor Details</h2>
<div class="row">
<div class="col-md-4 col-sm-4 col-xs-12 col-lg-4">
<p><label>Name<span>*</span></label>[text* sponsor_name id:sponsor_name class:sponsor_name_class]</p>
</div>
<div class="col-md-4 col-sm-4 col-xs-12 col-lg-4">
<p><label>Email<span>*</span></label>[email* sponsor_email id:sponsor_email class:sponsor_email]</p>
</div>
<div class="col-md-4 col-sm-4 col-xs-12 col-lg-4">
<p><label>Mobile Number<span>*</span></label>[tel* sponsor_tel id:sponsor_tel class:sponsor_name_tel]</p>
</div>
</div>
<h2>Applicant Details</h2>
<h5> (Note: Please enter the details of the Applicant's/Members to be Insured)</h5>
<p><label>No. of Applicant's</label>
[select noofapp id:noofapp class:noofapp_class "1" "2" "3"]</p>
<div class="row">
<div class="col-md-4 col-sm-4 col-xs-12 col-lg-4">
<p><label> Applicant's Name<span>*</span></label>
[text* app_name id:app_name class:app_name_class]</label></p>
</div>
<div class="col-md-4 col-sm-4 col-xs-12 col-lg-4">
<p><label> Email  </label>
   [email app_email id:app_email class:app_email_class]</p>
</div>
<div class="col-md-4 col-sm-4 col-xs-12 col-lg-4">
<p><label> Mobile Number</label>
[tel app_tel id:app_tel class:app_tel_class]</p>
</div>
<div class="col-md-3 col-sm-3 col-xs-12 col-lg-3">

</div>
</div>
<div class="row">
<div class="col-md-3 col-sm-3 col-xs-12 col-lg-3">
<p><label> Date of Birth<span>*</span> </label>
[date* Individual_dob id:Individual_dob class:Individual_dob_class]</p>

</div>
<div class="col-md-3 col-sm-3 col-xs-12 col-lg-3">
<p><label> Gender </label>
[radio IndividualGender id:IndividualGender class:IndividualGender use_label_element default:1 "Male" "Female"]</p>
</div>
<div class="col-md-3 col-sm-3 col-xs-12 col-lg-3">
<p><label> Maritial Status </label>
[select Individual_martialstatus id:Individual_martialstatus class:Individual_martialstatus_class "Not Married" "Married"]</p>
</div>
<div class="col-md-3 col-sm-3 col-xs-12 col-lg-3">
<p><label> Nationality <span>*</span> </label>
[text* Individualnationality id:Individualnationality class:Individualnationality_class]</p>
</div>
</div>
<div class="row">
<div class="col-md-7 col-sm-7 col-xs-12 col-lg-7">
<p><label> Insurance Category<span>*</span> </label>
[checkbox* InsuranceCategory use_label_element "Domestic workers"  "Parents & Parents In Law" "Married Females aged 18-45 years under sponsorship" "All Others, 0-65 yrs under sponsorship (Children, Employees salaried below AED 4,000)"]</p>
</div>
<div class="col-md-5 col-sm-5 col-xs-12 col-lg-5">
<p><label>Applicant's Relation to Sponsor<span>*</span> </label>
[select RelationType id:RelationType class:RelationType_class "Parents" "Parent in Law" "Wife" "Children" "Employee" "Domestic Worker"]</p>
</div>
</div>
<div class="row">
<div class="col-md-6 col-sm-6 col-xs-12 col-lg-6">
<p><label>Visa Issue<span>*</span> </label>
[select* visa_location id:visa_location class:visa_location_class "Dubai" "Abu Dhabi" "Sharjah" "Ras al Khaimah" "Ajman" "Fujairah" "Umm Al Quwain"]</p>
</div>
<div class="col-md-6 col-sm-6 col-xs-12 col-lg-6">
<p><label>Residence Location<span>*</span> </label>
[select* resident_visa id:resident_visa class:resident_visa_class "Dubai" "Abu Dhabi" "Sharjah" "Ras al Khaimah" "Ajman" "Fujairah" "Umm Al Quwain"]</p>
</div>
</div>

[group group_individual1]
<hr></hr>
<h4>Applicant 2 Details</h4>
<div class="row">
<div class="col-md-4 col-sm-4 col-xs-12 col-lg-4">
<p><label> Applicant's Name<span>*</span></label>
[text* app_name1 id:app_name1 class:app_name_class1]</label></p>
</div>
<div class="col-md-4 col-sm-4 col-xs-12 col-lg-4">
<p><label> Email  </label>
   [email app_email1 id:app_email1 class:app_email_class1]</p>
</div>
<div class="col-md-4 col-sm-4 col-xs-12 col-lg-4">
<p><label> Mobile Number</label>
[tel app_tel1 id:app_tel1 class:app_tel_class1]</p>
</div>
</div>
<div class="row">
<div class="col-md-3 col-sm-3 col-xs-12 col-lg-3">
<p><label> Date of Birth<span>*</span> </label>
[date* app_dob1 id:app_dob1 class:app_dob_class1]</p>

</div>
<div class="col-md-3 col-sm-3 col-xs-12 col-lg-3">
<p><label> Gender </label>
[radio appGender1 id:appGender1 class:appGender1 use_label_element default:1 "Male" "Female"]</p>
</div>
<div class="col-md-3 col-sm-3 col-xs-12 col-lg-3">
<p><label> Maritial Status </label>
[select appmartialstatus1 id:appmartialstatus1 class:appmartialstatus_class1 "Not Married" "Married"]</p>
</div>
<div class="col-md-3 col-sm-3 col-xs-12 col-lg-3">
<p><label> Nationality <span>*</span> </label>
[text* appnationality1 id:appnationality1 class:appnationality_class1]</p>
</div>
</div>
<div class="row">
<div class="col-md-7 col-sm-7 col-xs-12 col-lg-7">
<p><label> Insurance Category<span>*</span> </label>
[checkbox* InsuranceCategory1 use_label_element "Domestic workers"  "Parents & Parents In Law" "Married Females aged 18-45 years under sponsorship" "All Others, 0-65 yrs under sponsorship (Children, Employees salaried below AED 4,000)"]</p>
</div>
<div class="col-md-5 col-sm-5 col-xs-12 col-lg-5">
<p><label>Applicant's Relation to Sponsor<span>*</span> </label>
[select RelationType1 id:RelationType1 class:RelationType_class1 "Parents" "Parent in Law" "Wife" "Children" "Employee" "Domestic Worker"]</p>
</div>
</div>
<div class="row">
<div class="col-md-6 col-sm-6 col-xs-12 col-lg-6">
<p><label>Visa Issue<span>*</span> </label>
[select* visa_location1 id:visa_location class:visa_location_class "Dubai" "Abu Dhabi" "Sharjah" "Ras al Khaimah" "Ajman" "Fujairah" "Umm Al Quwain"]</p>
</div>
<div class="col-md-6 col-sm-6 col-xs-12 col-lg-6">
<p><label>Residence Location<span>*</span> </label>
[select* resident_visa1 id:resident_visa class1:resident_visa_class1 "Dubai" "Abu Dhabi" "Sharjah" "Ras al Khaimah" "Ajman" "Fujairah" "Umm Al Quwain"]</p>
</div>
</div>
[/group]

[group group_individual2]
<hr></hr>
<h4>Applicant 3 Details</h4>
<div class="row">
<div class="col-md-4 col-sm-4 col-xs-12 col-lg-4">
<p><label> Applicant's Name<span>*</span></label>
[text* app_name2 id:app_name2 class:app_name_class2]</label></p>
</div>
<div class="col-md-4 col-sm-4 col-xs-12 col-lg-4">
<p><label> Email  </label>
   [email app_email2 id:app_email2 class:app_email_class2]</p>
</div>
<div class="col-md-4 col-sm-4 col-xs-12 col-lg-4">
<p><label> Mobile Number</label>
[tel app_tel2 id:app_tel2 class:app_tel_class2]</p>
</div>
</div>
<div class="row">
<div class="col-md-3 col-sm-3 col-xs-12 col-lg-3">
<p><label> Date of Birth<span>*</span> </label>
[date* app_dob2 id:app_dob2 class:app_dob_class2]</p>

</div>
<div class="col-md-3 col-sm-3 col-xs-12 col-lg-3">
<p><label> Gender </label>
[radio appGender2 id:appGender2 class:appGender2 use_label_element default:1 "Male" "Female"]</p>
</div>
<div class="col-md-3 col-sm-3 col-xs-12 col-lg-3">
<p><label> Maritial Status </label>
[select appmartialstatus2 id:appmartialstatus2 class:appmartialstatus_class2 "Not Married" "Married"]</p>
</div>
<div class="col-md-3 col-sm-3 col-xs-12 col-lg-3">
<p><label> Nationality <span>*</span> </label>
[text* appnationality2 id:appnationality2 class:appnationality_class2]</p>
</div>
</div>
<div class="row">
<div class="col-md-7 col-sm-7 col-xs-12 col-lg-7">
<p><label> Insurance Category<span>*</span> </label>
[checkbox* InsuranceCategory2 use_label_element "Domestic workers"  "Parents & Parents In Law" "Married Females aged 18-45 years under sponsorship" "All Others, 0-65 yrs under sponsorship (Children, Employees salaried below AED 4,000)"]</p>
</div>
<div class="col-md-5 col-sm-5 col-xs-12 col-lg-5">
<p><label>Applicant's Relation to Sponsor<span>*</span> </label>
[select RelationType2 id:RelationType2 class:RelationType_class2 "Parents" "Parent in Law" "Wife" "Children" "Employee" "Domestic Worker"]</p>
</div>
</div>
<div class="row">
<div class="col-md-6 col-sm-6 col-xs-12 col-lg-6">
<p><label>Visa Issue<span>*</span> </label>
[select* visa_location2 id:visa_location class:visa_location_class "Dubai" "Abu Dhabi" "Sharjah" "Ras al Khaimah" "Ajman" "Fujairah" "Umm Al Quwain"]</p>
</div>
<div class="col-md-6 col-sm-6 col-xs-12 col-lg-6">
<p><label>Residence Location<span>*</span> </label>
[select* resident_visa2 id:resident_visa class2:resident_visa_class2 "Dubai" "Abu Dhabi" "Sharjah" "Ras al Khaimah" "Ajman" "Fujairah" "Umm Al Quwain"]</p>
</div>
</div>

[/group]

[/group]
[submit id:Submit_inquiry class:Submit_inquiry_class "Submit Inquiry"]