@extends('layouts.frontend')
@section('title', 'Cover page')
@section('content')  
<div class="clearfix"></div>
<section class="inner-content">
  <div class="clearfix"></div>
  <div class="container">
    <div class="form-block col-md-9 padding-left-none">
      <h2 class="product-title">{{ $product_details->product_name}}</h2>
      @if(Session::get('success'))
        <div class="alert alert-success">
          {{Session::get('success')}}
        </div>
      @endif
        @if(Session::get('failure'))
          <div class="alert alert-danger">
            {{Session::get('failure')}}
          </div>
      @endif
      <form name="underwritingForm" id="underwritingForm" action="{{url('cover-post')}}" method="post">
      <input type="hidden" name="_token" value="{{ csrf_token() }}">
        <div class="bg cover-questions">
          <div class="steps-tabs">
            <ul >
              
              <li class="active">Cover <i class="fa fa-chevron-right" aria-hidden="true"></i></li>
              <li >Bank Details <i class="fa fa-chevron-right" aria-hidden="true"></i></li>
              <li >Confirmation <i class="fa fa-chevron-right" aria-hidden="true"></i></li>
            </ul>
          </div>

          <!--<div class="form-group" >
            <div class="col-sm-12">
              <p>{{$product_details->product_info1}}</p>
              <ul class="links">
                <li><a target="_blank" href="{{ URL::asset('assets/policydocuments') }}/{{$product_details->policy_wordings_doc}}" > Policy Wordings</a> <i class="fa fa-file-pdf-o" style="color:red" aria-hidden="true"></i></li>
                <li><a target="_blank" href="{{ URL::asset('assets/policydocuments') }}/{{$product_details->keyfacts_doc}}">IPID Document</a> <i class="fa fa-file-pdf-o" style="color:red" aria-hidden="true"></i></li>
                
              </ul>
              <p>{!!$product_details->product_info2!!}</p>
            </div>
          </div>-->

          

          <div class="form-group" id="declaration">

          <label class="control-label col-sm-12 text-left"><h3>Declaration</h3></label>

          <p>{!!$product_details->product_info2!!}</p>

           
            <div class="col-sm-12">
              <div style="height:125px;overflow:auto;border:5px solid #ccc;-moz-border-radius:5px;padding-left:10px;">

                @if($personal_data->product_id=="39" && $personal_data->emp_status=="Self-Employed")

                {!!$product_details->your_policy_doc_text!!} 

                @else
                  {!!$product_details->disclaimer!!} 
                @endif

              
              <!-- @if($product_details->id == Config::get('constant.SHEPHERDS_FRIENDLY_LONGTERM') || $product_details->id == Config::get('constant.SHEPHERDS_FRIENDLY_SHORTERM'))

                <p style="color:#e87300"> Important Information</p>
                <ul>
                <li>You are applying for an income protection policy and the answers provided in this application form are your responsibility. It is important that you take reasonable care to answer the questions honestly and to the best of your knowledge; failure to do so may result in your policy being canceled, the terms of your policy being amended, your claim rejected or not fully paid. If you are unsure whether or not any details are relevant, you should include them or you may wish to consult your doctor before completing the application.</li>
                <li>If there are any changes to your health or other circumstances prior to your policy starting please inform us immediately. These include a change in occupation, earnings, employment status, travel or residence, the taking up of a hazardous pastime, a change in your own health or that of your father, mother and / or siblings (including half-siblings) and changes to your alcohol consumption and / or smoking habits.</li>
                <li>The Society reserves the right to apply special terms or higher premiums or postpone or decline any application.</li>
                <li>Please note that no cover is effective until your policy starts. We also recommend that any existing cover is not canceled until this policy starts and you are satisfied that it meets your needs.</li>
                <p><b>Long Term and Short Term Protect Policies only </b>- The Society will only cover you for benefit payments up to 70% of annual taxable income in the 12 months prior to your incapacity (“the Maximum Benefit Level”). Therefore, in the event of a claim, the Society will only make benefit payments up to the Maximum Benefit Level, regardless of the amount of benefit payments which you have asked for under the Policy. In the event of a claim you will be asked to provide evidence of your income in the 12 months immediately prior to your incapacity. Failure to provide such evidence will result in your claim not being paid. When assessing your benefit, we will also take into account any continuing payments from your employment or business such as sick pay, payments from other insurance policies and any other sources of income. State benefits will be taken into account if a claim extends beyond 12 months.</p>
                @else
                  {!!$product_details->disclaimer!!}  

                @endif   -->
              </div><br />
                      
                <div>If you don't understand any point, please contact us for further information. The documents above contain important information relating to the policy that you are about to purchase and on which we will rely in the event of a claim.
                  
                <!--<br><br>
                This exclusion applies for Accident, Sickness and Hospitalisation part of the cover only.<br>
                Please note until further notice, all claims directly or indirectly due to Coronavirus are excluded. This Insurance does not cover any claim in any way caused by or resulting from:<br>

                a) Coronavirus disease (COVID-19);<br>

                b) Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2);<br>

                c) Any mutation or variation of SARS-CoV-2;</br>

                d) Any fear or threat of a), b) or c) above.<br>
                
                e) Any other pandemic.<br>
                <br>-->
              
              </div>

              <input type="checkbox" name="declaration_confirm" id="declaration_confirm"  class="required"    {{ ($personal_data->declaration_confirm == 'on' ? "checked":"") }} />
                 &nbsp;I confirm
                            
              <div class="clearfix"></div>
              <label for="declaration_confirm" generated="true" class="error"style="display:none;"></label>
                       
            </div>        
            
          </div>
          

          <label class="control-label col-sm-12 text-left"><h3>Eligibility</h3></label>
          <div style="padding-bottom:5px;font-size:13px;color:#666;font-weight:bold;padding-top:10px;">You declare to the best of your knowledge and belief that all statements made are true, accurate and complete, please be aware if these statements are not true, accurate and complete it could mean your claim may be declined and or your policy cancelled.</div>

          @foreach ($questions as $key=>$value)
            @if(isset($value) && $value != '')
              <div class="fornRow">
                <table width="100%" border="0" cellspacing="0" cellpadding="0">
                  <tr>
                    <td width="29" align="left" valign="middle" class="blue">
                         
                        <a href="javascript:void(0)" class="hintanchor"><img src="{{ asset('assets/images/help-2.gif') }}" width="21" height="21" title='Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer'/></a>
                        <!-- <a href="javascript:void(0)" onmouseout="UnTip()" onmouseover="Tip('Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer')" class="hintanchor"><img src="{{ asset('assets/images/help-2.gif') }}" width="21" height="21" title='Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer'/></a> -->            </td>
                        <td width="421" align="left" valign="middle" class="blue">
                            <strong><span style="color:red">*</span> {!! $value !!}</strong>
                        </td>
                        <td width="148" align="left" valign="middle"><table border="0" cellspacing="4" cellpadding="4">
                          <tr>
                            <td width="105" align="left" valign="middle">
                              <input  name="{{ $key }}" id="{{ $key }}_opt1" type='radio' value='Yes' class="required" title="Please Answer this question" {{ (isset($underwriting_questions_data) && $underwriting_questions_data->$key  == 'Yes' ? "checked":"") }}/> Yes 
                            </td>

                            <td width="100" align="left" valign="middle">
                              <input   name="{{ $key }}" id="{{ $key }}_opt2" type='radio' value='No' {{ (isset($underwriting_questions_data) && $underwriting_questions_data->$key  == 'No' ? "checked":"") }}/>No
                            </td>
                          </tr>
                          <tr> 
                            <td align="left" valign="middle" colspan="2">
                              <label for="{{ $key }}" generated="true" class="error" style="display:none;">Please Answer this question</label>
                            </td>
                          </tr>
                    </table></td>
                  </tr>
                </table>
                @if($key == 'question2' && $personal_data->product_id != 13)
                <div id="question2_Nomsg" style="display: none;">
                  <table width="100%" border="0" cellspacing="0" cellpadding="5" style="padding-left:25px; ">
                      <tr>
                      <div id="seconderrormsg">
                      <td style="color:#FF0000;">
                          <strong>Please enter the relevant details below</strong>
                      </td>
                      </div>  
                      </tr>
                      <tr>
                      <td>
                          <textarea rows="3" cols="30" id="desc" name="desc" class="medical_desc_box" title="Please Enter Text" onKeyDown="limitText(this.form.desc,this.form.countdown,1000);" onKeyUp="limitText(this.form.desc,this.form.countdown,1000);" ></textarea>
                              <font size="1"><input readonly type="text" id="countdown" class="countdown_box" name="countdown" size="3" value="1000"> characters left.</font>
                      </td>
                      </tr>
                  </table>
                </div>
                @endif
              </div>
            @endif

          @endforeach
            <div class="fornRow" id="extra_question" style="display:none;">
            <table width="100%" border="0" cellspacing="0" cellpadding="0">
             <tr>
                    <td width="29" align="left" valign="middle" class="blue">
                         
                        <a href="javascript:void(0)" class="hintanchor"><img src="{{ asset('assets/images/help-2.gif') }}" width="21" height="21" title='Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer'/></a>
                        <!-- <a href="javascript:void(0)" onmouseout="UnTip()" onmouseover="Tip('Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer')" class="hintanchor"><img src="{{ asset('assets/images/help-2.gif') }}" width="21" height="21" title='Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer'/></a> -->            </td>
                        <td width="421" align="left" valign="middle" class="blue">
                            <strong><span style="color:red">*</span> Do you intend to cancel your existing policy if this application is accepted? you can still proceed?</strong>
                        </td>

                        @if($personal_data->product_id=="35" )
                        <td width="148" align="left" valign="middle"><table border="0" cellspacing="4" cellpadding="4">
                          <tr>
                            <td width="105" align="left" valign="middle">
                              <input  name="question15" id="question15_opt1" type='radio' value='Yes' class="required" title="Please Answer this question" {{ (isset($underwriting_questions_data) && $underwriting_questions_data->question15  == 'Yes' ? "checked":"") }}/> Yes 
                            </td>

                            <td width="100" align="left" valign="middle">
                              <input   name="question15" id="question15_opt2" type='radio' value='No' {{ (isset($underwriting_questions_data) && $underwriting_questions_data->question15  == 'No' ? "checked":"") }}/>No
                            </td>
                          </tr>
                          <tr> 
                            <td align="left" valign="middle" colspan="2">
                              <label for="question15" generated="true" class="error" style="display:none;">Please Answer this question</label>
                            </td>
                          </tr>
                    </table></td>
                    @endif

                    @if($personal_data->product_id=="38" || $personal_data->product_id=="36" )
                        <td width="148" align="left" valign="middle"><table border="0" cellspacing="4" cellpadding="4">
                          <tr>
                            <td width="105" align="left" valign="middle">
                              <input  name="question14" id="question14_opt1" type='radio' value='Yes' class="required" title="Please Answer this question" {{ (isset($underwriting_questions_data) && $underwriting_questions_data->question14  == 'Yes' ? "checked":"") }}/> Yes 
                            </td>

                            <td width="100" align="left" valign="middle">
                              <input   name="question14" id="question14_opt2" type='radio' value='No' {{ (isset($underwriting_questions_data) && $underwriting_questions_data->question14  == 'No' ? "checked":"") }}/>No
                            </td>
                          </tr>
                          <tr> 
                            <td align="left" valign="middle" colspan="2">
                              <label for="question15" generated="true" class="error" style="display:none;">Please Answer this question</label>
                            </td>
                          </tr>
                    </table></td>
                    @endif

                    @if($personal_data->product_id=="37" || $personal_data->product_id=="34")
                        <td width="148" align="left" valign="middle"><table border="0" cellspacing="4" cellpadding="4">
                          <tr>
                            <td width="105" align="left" valign="middle">
                              <input  name="question9" id="question9_opt1" type='radio' value='Yes' class="required" title="Please Answer this question" {{ (isset($underwriting_questions_data) && $underwriting_questions_data->question9  == 'Yes' ? "checked":"") }}/> Yes 
                            </td>

                            <td width="100" align="left" valign="middle">
                              <input   name="question9" id="question9_opt2" type='radio' value='No' {{ (isset($underwriting_questions_data) && $underwriting_questions_data->question9  == 'No' ? "checked":"") }}/>No
                            </td>
                          </tr>
                          <tr> 
                            <td align="left" valign="middle" colspan="2">
                              <label for="question9" generated="true" class="error" style="display:none;">Please Answer this question</label>
                            </td>
                          </tr>
                    </table></td>
                    @endif
                  </tr>
                </table>
              </div>
            @if($personal_data->product_id=="38")
            <div class="fornRow" id="questionno15">
            <table width="100%" border="0" cellspacing="0" cellpadding="0">
             <tr>
                    <td width="29" align="left" valign="middle" class="blue">
                         
                        <a href="javascript:void(0)" class="hintanchor"><img src="{{ asset('assets/images/help-2.gif') }}" width="21" height="21" title='Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer'/></a>
                        <!-- <a href="javascript:void(0)" onmouseout="UnTip()" onmouseover="Tip('Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer')" class="hintanchor"><img src="{{ asset('assets/images/help-2.gif') }}" width="21" height="21" title='Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer'/></a> -->            </td>
                        <td width="421" align="left" valign="middle" class="blue">
                            <strong><span style="color:red">*</span> Are you transferring cover from another provider?</strong>
                        </td>


                    
                        <td width="148" align="left" valign="middle"><table border="0" cellspacing="4" cellpadding="4">
                          <tr>
                            <td width="105" align="left" valign="middle">
                              <input  name="question13" id="question13_opt1" type='radio' value='Yes' class="required" title="Please Answer this question" {{ (isset($underwriting_questions_data) && $underwriting_questions_data->question13  == 'Yes' ? "checked":"") }}/> Yes 
                            </td>

                            <td width="100" align="left" valign="middle">
                              <input   name="question13" id="question13_opt2" type='radio' value='No' {{ (isset($underwriting_questions_data) && $underwriting_questions_data->question14  == 'No' ? "checked":"") }}/>No
                            </td>
                          </tr>
                          <tr> 
                            <td align="left" valign="middle" colspan="2">
                              <label for="question13" generated="true" class="error" style="display:none;">Please Answer this question</label>
                            </td>
                          </tr>
                    </table></td>
                   
                   
                  </tr>
                </table>
              </div>
              @endif



             @if($personal_data->product_id=="40")
            <div class="fornRow" id="questionno10">
            <table width="100%" border="0" cellspacing="0" cellpadding="0">
             <tr>
                    <td width="29" align="left" valign="middle" class="blue">
                         
                        <a href="javascript:void(0)" class="hintanchor"><img src="{{ asset('assets/images/help-2.gif') }}" width="21" height="21" title='Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer'/></a>
                        <!-- <a href="javascript:void(0)" onmouseout="UnTip()" onmouseover="Tip('Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer')" class="hintanchor"><img src="{{ asset('assets/images/help-2.gif') }}" width="21" height="21" title='Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer'/></a> -->            </td>
                        <td width="421" align="left" valign="middle" class="blue">
                            <strong><span style="color:red">*</span> Are you transferring cover from another provider?</strong>
                        </td>


                    
                        <td width="148" align="left" valign="middle"><table border="0" cellspacing="4" cellpadding="4">
                          <tr>
                            <td width="105" align="left" valign="middle">
                              <input  name="question11" id="question11_opt1" type='radio' value='Yes' class="required" title="Please Answer this question" {{ (isset($underwriting_questions_data) && $underwriting_questions_data->question10  == 'Yes' ? "checked":"") }}/> Yes 
                            </td>

                            <td width="100" align="left" valign="middle">
                              <input   name="question11" id="question11_opt2" type='radio' value='No' {{ (isset($underwriting_questions_data) && $underwriting_questions_data->question10  == 'No' ? "checked":"") }}/>No
                            </td>
                          </tr>
                          <tr> 
                            <td align="left" valign="middle" colspan="2">
                              <label for="question10" generated="true" class="error" style="display:none;">Please Answer this question</label>
                            </td>
                          </tr>
                    </table></td>
                   
                   
                  </tr>
                </table>
              </div>
              @endif


            <div class="fornRow" id="extra_question_incomebeeasu" style="display:none;">
            <table width="100%" border="0" cellspacing="0" cellpadding="0">
             <tr>
                    <td width="29" align="left" valign="middle" class="blue">
                         
                        <a href="javascript:void(0)" class="hintanchor"><img src="{{ asset('assets/images/help-2.gif') }}" width="21" height="21" title='Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer'/></a>
                        <!-- <a href="javascript:void(0)" onmouseout="UnTip()" onmouseover="Tip('Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer')" class="hintanchor"><img src="{{ asset('assets/images/help-2.gif') }}" width="21" height="21" title='Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer'/></a> -->            </td>
                        <td width="421" align="left" valign="middle" class="blue">
                            <strong><span style="color:red">*</span> Current policy Insurer </strong>
                        </td>

                       
                        <td width="148" align="left" valign="middle"> <input type="text" name="transfer_insurer_incomebee" id="transfer_insurer_incomebee"></td>
                   

                   
                  </tr>

                  <tr>
                    <td width="29" align="left" valign="middle" class="blue">
                         
                        <a href="javascript:void(0)" class="hintanchor"><img src="{{ asset('assets/images/help-2.gif') }}" width="21" height="21" title='Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer'/></a>
                        <!-- <a href="javascript:void(0)" onmouseout="UnTip()" onmouseover="Tip('Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer')" class="hintanchor"><img src="{{ asset('assets/images/help-2.gif') }}" width="21" height="21" title='Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer'/></a> -->            </td>
                        <td width="421" align="left" valign="middle" class="blue">
                            <strong><span style="color:red">*</span> Original Policy Start date </strong>
                        </td>

                       
                        <td width="148" align="left" valign="middle"> <input type="text" name="transfer_insurance_startdate_incomebee" id="transfer_insurance_startdate_incomebee"></td>
                   

                   
                  </tr>

                  <tr>
                    <td width="29" align="left" valign="middle" class="blue">
                         
                        <a href="javascript:void(0)" class="hintanchor"><img src="{{ asset('assets/images/help-2.gif') }}" width="21" height="21" title='Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer'/></a>
                        <!-- <a href="javascript:void(0)" onmouseout="UnTip()" onmouseover="Tip('Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer')" class="hintanchor"><img src="{{ asset('assets/images/help-2.gif') }}" width="21" height="21" title='Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer'/></a> -->            </td>
                        <td width="421" align="left" valign="middle" class="blue">
                            <strong><span style="color:red">*</span> Select Current Policy Type </strong>
                        </td>

                       
                        <td width="148" align="left" valign="middle"> 
                          <select name="current_policy_type_incomebee" id="current_policy_type_incomebee">
                            <option value="">Select Type</option>
                            <option value="AS">Accident & Sickness</option>
                            <option value="U">Unemployment</option>
                            <option value="ASU">Accident Sickness and Unemployment</option>
                        </td>
                   

                   
                  </tr>


                  <tr>
                    <td width="29" align="left" valign="middle" class="blue">
                         
                        <a href="javascript:void(0)" class="hintanchor"><img src="{{ asset('assets/images/help-2.gif') }}" width="21" height="21" title='Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer'/></a>
                        <!-- <a href="javascript:void(0)" onmouseout="UnTip()" onmouseover="Tip('Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer')" class="hintanchor"><img src="{{ asset('assets/images/help-2.gif') }}" width="21" height="21" title='Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer'/></a> -->            </td>
                        <td width="421" align="left" valign="middle" class="blue">
                            <strong><span style="color:red">*</span> Current Policy Monthly Benefit </strong>
                        </td>

                       
                        <td width="148" align="left" valign="middle"> <input type="text" name="current_monthly_benefit_incomebee" id="current_monthly_benefit_incomebee"></td>
                   

                   
                  </tr>


                    <tr>
                    <td width="29" align="left" valign="middle" class="blue">
                         
                        <a href="javascript:void(0)" class="hintanchor"><img src="{{ asset('assets/images/help-2.gif') }}" width="21" height="21" title='Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer'/></a>
                        <!-- <a href="javascript:void(0)" onmouseout="UnTip()" onmouseover="Tip('Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer')" class="hintanchor"><img src="{{ asset('assets/images/help-2.gif') }}" width="21" height="21" title='Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer'/></a> -->            </td>
                        <td width="421" align="left" valign="middle" class="blue">
                            <strong><span style="color:red">*</span> Current Policy Excess Period </strong>
                        </td>

                       
                        <td width="148" align="left" valign="middle"> 
                          <select name="current_policy_excess_incomebee" id="current_policy_excess_incomebee">
                            <option value="">Select Excess Period</option>
                            <option value="1">Back to Day 1</option>
                            <option value="30">30 Days</option>
                            <option value="60">60 Days</option>
                        </td>
                   

                   
                  </tr>

                    <tr><td colspan="3">*Please note, any enhancements to unemployment cover will be subject to the initial exclusion period</td></tr>

                    <tr>
                    <td width="29" align="left" valign="middle" class="blue">
                         
                        <a href="javascript:void(0)" class="hintanchor"><img src="{{ asset('assets/images/help-2.gif') }}" width="21" height="21" title='Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer'/></a>
                        <!-- <a href="javascript:void(0)" onmouseout="UnTip()" onmouseover="Tip('Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer')" class="hintanchor"><img src="{{ asset('assets/images/help-2.gif') }}" width="21" height="21" title='Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer'/></a> -->            </td>
                        <td width="421" align="left" valign="middle" class="blue">
                            <strong><span style="color:red">*</span> Have you made any claims on the policy in the last 6 months?</strong>
                        </td>

                       
                        <td width="148" align="left" valign="middle"><table border="0" cellspacing="4" cellpadding="4">
                          <tr>
                            <td width="105" align="left" valign="middle">
                              <input  name="extra_incomebee_15" id="extra_incomebee_15_opt1" type='radio' value='Yes' class="required" title="Please Answer this question" /> Yes 
                            </td>

                            <td width="100" align="left" valign="middle">
                              <input   name="extra_incomebee_15" id="extra_incomebee_15_opt2" type='radio' value='No' checked/>No
                            </td>
                          </tr>
                          <tr> 
                            <td align="left" valign="middle" colspan="2">
                              <label for="question15" generated="true" class="error" style="display:none;">Please Answer this question</label>
                            </td>
                          </tr>
                    </table></td></tr>
                  
                </table>
              </div>
            <div class="fornRow" id="extra_question_incomeanchorasu" style="display:none;">
            <table width="100%" border="0" cellspacing="0" cellpadding="0">
             <tr>
                    <td width="29" align="left" valign="middle" class="blue">
                         
                        <a href="javascript:void(0)" class="hintanchor"><img src="{{ asset('assets/images/help-2.gif') }}" width="21" height="21" title='Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer'/></a>
                        <!-- <a href="javascript:void(0)" onmouseout="UnTip()" onmouseover="Tip('Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer')" class="hintanchor"><img src="{{ asset('assets/images/help-2.gif') }}" width="21" height="21" title='Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer'/></a> -->            </td>
                        <td width="421" align="left" valign="middle" class="blue">
                            <strong><span style="color:red">*</span> Current policy Insurer </strong>
                        </td>

                       
                        <td width="148" align="left" valign="middle"> <input type="text" name="transfer_insurer" id="transfer_insurer"></td>
                   

                   
                  </tr>

                  <tr>
                    <td width="29" align="left" valign="middle" class="blue">
                         
                        <a href="javascript:void(0)" class="hintanchor"><img src="{{ asset('assets/images/help-2.gif') }}" width="21" height="21" title='Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer'/></a>
                        <!-- <a href="javascript:void(0)" onmouseout="UnTip()" onmouseover="Tip('Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer')" class="hintanchor"><img src="{{ asset('assets/images/help-2.gif') }}" width="21" height="21" title='Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer'/></a> -->            </td>
                        <td width="421" align="left" valign="middle" class="blue">
                            <strong><span style="color:red">*</span> Original Policy Start date </strong>
                        </td>

                       
                        <td width="148" align="left" valign="middle"> <input type="text" name="transfer_insurance_startdate" id="transfer_insurance_startdate"></td>
                   

                   
                  </tr>


                    <tr>
                    <td width="29" align="left" valign="middle" class="blue">
                         
                        <a href="javascript:void(0)" class="hintanchor"><img src="{{ asset('assets/images/help-2.gif') }}" width="21" height="21" title='Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer'/></a>
                        <!-- <a href="javascript:void(0)" onmouseout="UnTip()" onmouseover="Tip('Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer')" class="hintanchor"><img src="{{ asset('assets/images/help-2.gif') }}" width="21" height="21" title='Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer'/></a> -->            </td>
                        <td width="421" align="left" valign="middle" class="blue">
                            <strong><span style="color:red">*</span> Select Current Policy Type </strong>
                        </td>

                       
                        <td width="148" align="left" valign="middle"> 
                          <select name="current_policy_type_incomeanchor" id="current_policy_type_incomeanchor">
                            <option value="">Select Type</option>
                            <option value="AS">Accident & Sickness</option>
                            <option value="U">Unemployment</option>
                            <option value="ASU">Accident Sickness and Unemployment</option>
                        </td>
                   

                   
                  </tr>


                  <tr>
                    <td width="29" align="left" valign="middle" class="blue">
                         
                        <a href="javascript:void(0)" class="hintanchor"><img src="{{ asset('assets/images/help-2.gif') }}" width="21" height="21" title='Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer'/></a>
                        <!-- <a href="javascript:void(0)" onmouseout="UnTip()" onmouseover="Tip('Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer')" class="hintanchor"><img src="{{ asset('assets/images/help-2.gif') }}" width="21" height="21" title='Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer'/></a> -->            </td>
                        <td width="421" align="left" valign="middle" class="blue">
                            <strong><span style="color:red">*</span> Current Policy Monthly Benefit </strong>
                        </td>

                       
                        <td width="148" align="left" valign="middle"> <input type="text" name="current_monthly_benefit_incomeanchor" id="current_monthly_benefit_incomeanchor"></td>
                   

                   
                  </tr>


                    <tr>
                    <td width="29" align="left" valign="middle" class="blue">
                         
                        <a href="javascript:void(0)" class="hintanchor"><img src="{{ asset('assets/images/help-2.gif') }}" width="21" height="21" title='Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer'/></a>
                        <!-- <a href="javascript:void(0)" onmouseout="UnTip()" onmouseover="Tip('Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer')" class="hintanchor"><img src="{{ asset('assets/images/help-2.gif') }}" width="21" height="21" title='Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer'/></a> -->            </td>
                        <td width="421" align="left" valign="middle" class="blue">
                            <strong><span style="color:red">*</span> Current Policy Excess Period </strong>
                        </td>

                       
                        <td width="148" align="left" valign="middle"> 
                          <select name="current_policy_excess_incomeanchor" id="current_policy_excess_incomeanchor">
                            <option value="">Select Excess Period</option>
                            <option value="1">Back to Day 1</option>
                            <option value="30">30 Days</option>
                            <option value="60">60 Days</option>
                        </td>
                   

                   
                  </tr>

                  <tr><td colspan="3" width="100%">*Please note, any enhancements to unemployment cover will be subject to the initial exclusion period</td></tr>

                    <tr>
                    <td width="29" align="left" valign="middle" class="blue">
                         
                        <a href="javascript:void(0)" class="hintanchor"><img src="{{ asset('assets/images/help-2.gif') }}" width="21" height="21" title='Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer'/></a>
                        <!-- <a href="javascript:void(0)" onmouseout="UnTip()" onmouseover="Tip('Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer')" class="hintanchor"><img src="{{ asset('assets/images/help-2.gif') }}" width="21" height="21" title='Please provide accurate answers. Any information not disclosed may result in your claim being disallowed by the insurer'/></a> -->            </td>
                        <td width="421" align="left" valign="middle" class="blue">
                            <strong><span style="color:red">*</span> Have you made any claims on the policy in the last 6 months?</strong>
                        </td>

                       
                        <td width="148" align="left" valign="middle"><table border="0" cellspacing="4" cellpadding="4">
                          <tr>
                            <td width="105" align="left" valign="middle">
                              <input  name="extra_incomeanchor_11" id="extra_incomeanchor_11_opt1" type='radio' value='Yes' class="required" title="Please Answer this question" /> Yes 
                            </td>

                            <td width="100" align="left" valign="middle">
                              <input   name="extra_incomeanchor_11" id="extra_incomeanchor_11_opt2" type='radio' value='No' checked/>No
                            </td>
                          </tr>
                          <tr> 
                            <td align="left" valign="middle" colspan="2">
                              <label for="question11" generated="true" class="error" style="display:none;">Please Answer this question</label>
                            </td>
                          </tr>
                    </table></td></tr>
                  
                </table>
              </div>

          <div id="error_msg" >
            <table width="100%" border="0" cellspacing="0" cellpadding="0">
              <tr>
                <td width="5%" align="left" valign="middle">&nbsp;
                       
                </td>
                <td width="226" class="error_validate" align="left" valign="middle" style="color:red;font-weight:bold;"><span id="err_display"></span></td>
                <td width="288" align="left" valign="middle">&nbsp;</td>
              </tr>
            </table>
          </div>

          <br clear="all" />

        </div> <!-- bg cover-questions end -->

        <input type="hidden" id="hidden_product_id" name="hidden_product_id" value="{{ $personal_data->product_id }}">
        <input type="hidden" id="hidden_quote_id" name="hidden_quote_id" value="{{ $personal_data->quote_id }}">
        <input type="hidden" id="cover_type" name="cover_type" value="{{ $personal_data->typeofcover }}">

        <div class="form-btns">
            
            <button type="submit" class="medium-btn btn-default pull-right" >Continue</button>
        </div>
      </form>
    </div> <!-- Left side content -->
    
    <div class="col-md-3 padding-none right-col border-left-none">
      @include('slices.frontend.get-a-quot.right_bottom')
      
    </div>

  </div>
</section>

<div class="clearfix"></div>
@endsection
@section('page-script')
<script type="text/javascript" src="https://code.jquery.com/jquery-2.0.0.js"></script>
<script src="https://ajax.aspnetcdn.com/ajax/jquery.validate/1.11.1/jquery.validate.js"></script>
<script src="{{ URL::asset('assets/js/get-a-quote/cover_page_v8.js') }}"></script>
@stop