<?php
// define variables and set to empty values

include('Secure/Cred.php');

    $plnbanda='';
    $plnbandb='';
    $plntpa='';
    $plnbandc='';
    $plnbandd='';
    $classreq= 'form-line';
    $formdivrequired = 'form-input';
    $reqicon = '';
    $xdogroupoplan='Family';
    $xdogroupoplan2='Individual';
    $xdoreadonly='';
    $plnbridgegap='';
    $changedfoundation='';
    $idlp='';
    $idlc='';
    $cmpvalu='Alleanza Default Company';
	if ($_SERVER["REQUEST_METHOD"] == "GET") {
	  $cmpxlink = trim(strtoupper($_GET["cllocation"]));
	}

        
    $m_queues = conn("SELECT * FROM (`web_app_enrollment_form`) WHERE `link`='".$cmpxlink."' LIMIT 1;");
	while(list($idx,$companyx,$linkx) = mysqli_fetch_array($m_queues,MYSQLI_NUM))
	{		
	$cmpvalu=$companyx;		
	$lnkvalu=$linkx;		
	
	}
	
	$m_queues1 = conn("SELECT state, location, provider_name FROM (`web_app_provider_list`) WHERE `provider_category` like 'TPA%';");
	while(list($statex,$locationx,$provider_namex) = mysqli_fetch_array($m_queues1,MYSQLI_NUM))
	{		
	$plntpa.='<option value="'.$statex.' - '.$locationx.' - '.$provider_namex.'">'.$statex.' - '.$locationx.' - '.$provider_namex.'</option>';	
	
	}
	
	$m_queues2 = conn("SELECT state, location, provider_name FROM (`web_app_provider_list`) WHERE `provider_category` like 'BANDA%';");
	while(list($statex,$locationx,$provider_namex) = mysqli_fetch_array($m_queues2,MYSQLI_NUM))
	{		
	$plnbanda.='<option value="'.$statex.' - '.$locationx.' - '.$provider_namex.'">'.$statex.' - '.$locationx.' - '.$provider_namex.'</option>';	
	
	}
	
	$m_queues3 = conn("SELECT state, location, provider_name FROM (`web_app_provider_list`) WHERE `provider_category` like 'BANDB%';");
	while(list($statex,$locationx,$provider_namex) = mysqli_fetch_array($m_queues3,MYSQLI_NUM))
	{		
	$plnbandb.='<option value="'.$statex.' - '.$locationx.' - '.$provider_namex.'">'.$statex.' - '.$locationx.' - '.$provider_namex.'</option>';	
	
	}
	
	$m_queues4 = conn("SELECT state, location, provider_name FROM (`web_app_provider_list`) WHERE `provider_category` like 'BANDC%';");
	while(list($statex,$locationx,$provider_namex) = mysqli_fetch_array($m_queues4,MYSQLI_NUM))
	{		
	$plnbandc.='<option value="'.$statex.' - '.$locationx.' - '.$provider_namex.'">'.$statex.' - '.$locationx.' - '.$provider_namex.'</option>';	
	
	}
	
	$m_queues5 = conn("SELECT state, location, provider_name FROM (`web_app_provider_list`) WHERE `provider_category` like 'BANDD%';");
	while(list($statex,$locationx,$provider_namex) = mysqli_fetch_array($m_queues5,MYSQLI_NUM))
	{		
	$plnbandd.='<option value="'.$statex.' - '.$locationx.' - '.$provider_namex.'">'.$statex.' - '.$locationx.' - '.$provider_namex.'</option>';	
	
	}
	
	$m_queues6 = conn("SELECT state, location, provider_name FROM (`web_app_provider_list`) WHERE `provider_category` like 'BRIDGEGAP%';");
	while(list($statex,$locationx,$provider_namex) = mysqli_fetch_array($m_queues6,MYSQLI_NUM))
	{		
	$plnbridgegap.='<option value="'.$statex.' - '.$locationx.' - '.$provider_namex.'">'.$statex.' - '.$locationx.' - '.$provider_namex.'</option>';	
	
	}
	
	$m_queues7 = conn("SELECT state, location, provider_name FROM (`web_app_provider_list`) WHERE `provider_category` like 'CHANGEDFOUNDATION%';");
	while(list($statex,$locationx,$provider_namex) = mysqli_fetch_array($m_queues7,MYSQLI_NUM))
	{		
	$changedfoundation .='<option value="'.$statex.' - '.$locationx.' - '.$provider_namex.'">'.$statex.' - '.$locationx.' - '.$provider_namex.'</option>';	
	
	}
	
	$m_queues8 = conn("SELECT state, location, provider_name FROM (`web_app_provider_list`) WHERE `provider_category` like 'TINCAN_PLATINUM%';");
	while(list($statex,$locationx,$provider_namex) = mysqli_fetch_array($m_queues8,MYSQLI_NUM))
	{		
	$platinumtincan .='<option value="'.$statex.' - '.$locationx.' - '.$provider_namex.'">'.$statex.' - '.$locationx.' - '.$provider_namex.'</option>';	
	
	}
	
	$m_queues9 = conn("SELECT state, location, provider_name FROM (`web_app_provider_list`) WHERE `provider_category` like 'TINCAN_GOLDPLUS%';");
	while(list($statex,$locationx,$provider_namex) = mysqli_fetch_array($m_queues9,MYSQLI_NUM))
	{		
	$goldplustincan .='<option value="'.$statex.' - '.$locationx.' - '.$provider_namex.'">'.$statex.' - '.$locationx.' - '.$provider_namex.'</option>';	
	
	}
	
	$m_queues10 = conn("SELECT state, location, provider_name FROM (`web_app_provider_list`) WHERE `provider_category` like 'TESTB%';");
	while(list($statex,$locationx,$provider_namex) = mysqli_fetch_array($m_queues9,MYSQLI_NUM))
	{		
	$bandtest .='<option value="'.$statex.' - '.$locationx.' - '.$provider_namex.'">'.$statex.' - '.$locationx.' - '.$provider_namex.'</option>';	
	
	}
	
	$m_queues11 = conn("SELECT state, location, provider_name FROM (`web_app_provider_list`) WHERE `provider_category` like 'IDLP%';");
	while(list($statex,$locationx,$provider_namex) = mysqli_fetch_array($m_queues11,MYSQLI_NUM))
	{		
	$plnidlp.='<option value="'.$statex.' - '.$locationx.' - '.$provider_namex.'">'.$statex.' - '.$locationx.' - '.$provider_namex.'</option>';	
	
	}
	
	$m_queues12 = conn("SELECT state, location, provider_name FROM (`web_app_provider_list`) WHERE `provider_category` like 'IDLC%';");
	while(list($statex,$locationx,$provider_namex) = mysqli_fetch_array($m_queues12,MYSQLI_NUM))
	{		
	$plnidlc.='<option value="'.$statex.' - '.$locationx.' - '.$provider_namex.'">'.$statex.' - '.$locationx.' - '.$provider_namex.'</option>';	
	
	}
	
	$planinput30='<option value="Platinum Plan"> Platinum Plan </option>
				<option value="Diamond Plan "> Diamond Plan </option>
				<option value="Gold Plus Plan"> Gold Plus Plan </option>
				<option value="Gold Plan"> Gold Plan </option>
				<option value="Silver Plan"> Silver Plan </option>
				<option value="Standard Plan"> Standard Plan </option>
				<option value="TPA"> TPA </option>';
    
    if($cmpvalu=='CAPITALFIELD INVESTMENT GROUP LIMITED'){
		$planinput30='<option value="Diamond Plan "> Diamond Plan </option>
					  <option value="Silver Plan"> Silver Plan </option>'; 
		 }
    
    if($lnkvalu=='1603495820107558309I'){
		$planinput30='<option value="Standard Plan"> Standard Plan </option>';
        $xdoreadonly=' readonly';
        $xdogroupoplan='Individual'; 
		 }
    
    if($lnkvalu=='16361197561149341406I'){
        $planinput30='<option value="Gold Plus Plan"> Gold Plus Plan </option>'; 
		 }        
	
	
	if($lnkvalu=='16391254381190188378E'){
		$planinput30='<option value="Standard Plan"> Standard Plan </option>'; 
		 }  
		 
	if($lnkvalu=='16393496181206740166I'){
		$planinput30='<option value="Standard Plan"> Standard Plan </option>'; 
		 }   
		 
	if($lnkvalu=='163934956369382646I'){
		$planinput30='<option value="Standard Plan"> Standard Plan </option>'; 
		 }      
		 
	if($lnkvalu=='1639349498193928482E'){
		$planinput30='<option value="Standard Plan"> Standard Plan </option>'; 
		 }      
		 
	if($lnkvalu=='16397444611098269251A'){
		$planinput30='<option value="Silver Plan"> Silver Plan </option>'; 
		 }   
		 
	if($lnkvalu=='1639745616780072444V'){
		$planinput30='<option value="Platinum Plan"> Platinum Plan </option>'; 
		 }   
		 
	if($lnkvalu=='16397466191220488907M'){
		$planinput30='<option value="Standard Plan"> Standard Plan </option>'; 
		 }    
		 
	if($lnkvalu=='16397468161885297922I'){
		$planinput30='<option value="Standard Plan"> Standard Plan </option>'; 
		 }    
	
	if($lnkvalu=='16487432291818974445I'){
		$planinput30='<option value="Standard Plan"> Standard Plan </option>'; 
		 }     
		 
	if($lnkvalu=='16397470521198323562L'){
		$planinput30='<option value="Standard Plan"> Standard Plan </option>'; 
		 }   
		 
		 if($lnkvalu=='16425644381665103994E'){
		$planinput30='<option value="Silver Plan"> Silver Plan </option>
		                <option value="Gold Plan"> Gold Plan </option>'; 
		 }   
		 
		 if($lnkvalu=='1645801298544727132O'){
		$planinput30='<option value="Silver Plan"> Silver Plan </option>
		                <option value="Gold Plus Plan"> Gold Plan </option>'; 
		 }
		 
		 if($lnkvalu=='1652804171355864676R'){
		$planinput30='<option value="Diamond Plan "> Diamond Plan </option>
		              <option value="Gold Plus Plan"> Gold Plus Plan </option>';
		 }
		 
		 if($lnkvalu=='16475129112023900823I'){
		$planinput30='<option value="Platinum Plan"> Platinum Plan </option>'; 
		 }   
		 
		 if($lnkvalu=='16480238211288333174N'){
		     $xdogroupoplan2='Family';
		$planinput30='<option value="IDLC"> IDL CLASSIC </option>
		                <option value="IDLP"> IDL PRIME </option>'; 
		 }   
		 
		 if($lnkvalu=='16504508361864405205N'){
		$planinput30='<option value="Silver Plan"> Silver Plan </option>
		                <option value="Diamond Plan "> Diamond Plan </option>';
		$xdogroupoplan='Individual';
		 }
		 
		 if($lnkvalu=='16533718811200890293D'){
		$planinput30='<option value="Standard Plan"> Standard Plan </option>'; 
		 }  
		 
		 if($lnkvalu=='165466623220206369I'){
		$planinput30='<option value="Standard Plan"> Standard Plan </option>'; 
		$classreq = 'form-line jf-required';
		$reqicon ='*';
		$formdivrequired= 'form-input jf-required';
		 }  
		 
		 if($lnkvalu=='16547664911109718994A'){
		$planinput30='<option value="Silver Plan"> Silver Plan </option>
		                <option value="Gold Plus Plan"> Gold Plan </option>'; 
		 }
		 
		if($lnkvalu=='1657110743733117900I'){
		$planinput30='<option value="Standard Plan"> Standard Plan </option>'; 
		 }  
		
		if($lnkvalu=='16581460197437822418'){
		$planinput30='<option value="Standard Plan"> Standard Plan </option>'; 
		 }   
		 
		if($lnkvalu=='1660322453910723903L'){
		$planinput30='<option value="Standard Plan"> Standard Plan </option>'; 
		 }   
		 
		if($lnkvalu=='1661425395472648909L'){
		$planinput30='<option value="Standard Plan"> Standard Plan </option>'; 
		 }  
		 
		if($lnkvalu=='16618654841356055423H'){
		    $planinput30='<option value="Standard Plan"> Standard Plan </option>'; 
		 }  
		 
		 if($lnkvalu=='16642047261229834076I'){
		$planinput30='<option value="Standard Plan"> Standard Plan </option>
		                <option value="Platinum Plan"> Platinum Plan </option>'; 
		 }
		 
		 if($lnkvalu=='1664458643326132514-'){
		$planinput30='<option value="Standard Plan"> Standard Mini Plan </option>'; 
		$xdogroupoplan= 'Individual';
		 }  
?>



<!DOCTYPE html>
<html style="background-image: url(./final_20864245705555.5b18e0a95657b9.83368454.jpg); background-repeat: no-repeat;
  background-attachment: fixed;  
  background-size: cover; }">
    
<body>
<div id="outer" align="center" style="width:100%;">

<script src="https://cdnjs.cloudflare.com/ajax/libs/punycode/1.4.1/punycode.min.js"></script>
<script src="https://cdn.jotfor.ms/js/vendor/imageinfo.js?v=3.3.21109" type="text/javascript"></script>
<script src="https://cdn.jotfor.ms/static/prototype.forms.js" type="text/javascript"></script>
<script src="https://cdn.jotfor.ms/static/jotform.forms.js?3.3.21109" type="text/javascript"></script>
<script type="text/javascript">
	JotForm.init(function(){
if (window.JotForm && JotForm.accessible) $('input_98').setAttribute('tabindex',0);
if (window.JotForm && JotForm.accessible) $('input_4').setAttribute('tabindex',0);
if (window.JotForm && JotForm.accessible) $('input_26').setAttribute('tabindex',0);
if (window.JotForm && JotForm.accessible) $('input_27').setAttribute('tabindex',0);
if (window.JotForm && JotForm.accessible) $('input_29').setAttribute('tabindex',0);
      setTimeout(function() {
          $('input_24').hint('ex: myname@example.com');
       }, 20);
if (window.JotForm && JotForm.accessible) $('input_36').setAttribute('tabindex',0);
if (window.JotForm && JotForm.accessible) $('input_37').setAttribute('tabindex',0);
if (window.JotForm && JotForm.accessible) $('input_38').setAttribute('tabindex',0);
if (window.JotForm && JotForm.accessible) $('input_50').setAttribute('tabindex',0);
if (window.JotForm && JotForm.accessible) $('input_51').setAttribute('tabindex',0);
if (window.JotForm && JotForm.accessible) $('input_52').setAttribute('tabindex',0);
if (window.JotForm && JotForm.accessible) $('input_60').setAttribute('tabindex',0);
if (window.JotForm && JotForm.accessible) $('input_61').setAttribute('tabindex',0);
if (window.JotForm && JotForm.accessible) $('input_62').setAttribute('tabindex',0);
if (window.JotForm && JotForm.accessible) $('input_69').setAttribute('tabindex',0);
if (window.JotForm && JotForm.accessible) $('input_70').setAttribute('tabindex',0);
if (window.JotForm && JotForm.accessible) $('input_71').setAttribute('tabindex',0);
if (window.JotForm && JotForm.accessible) $('input_78').setAttribute('tabindex',0);
if (window.JotForm && JotForm.accessible) $('input_79').setAttribute('tabindex',0);
if (window.JotForm && JotForm.accessible) $('input_80').setAttribute('tabindex',0);
	JotForm.newDefaultTheme = false;
	JotForm.extendsNewTheme = false;
	JotForm.newPaymentUIForNewCreatedForms = false;
    /*INIT-END*/
	});

   JotForm.prepareCalculationsOnTheFly([null,null,{"name":"submitForm","qid":"2","text":"Submit Form","type":"control_button"},null,{"name":"surname","qid":"4","text":"Surname","type":"control_textbox"},null,null,null,null,{"name":"dateOf","qid":"9","text":"Date of Birth","type":"control_birthdate"},null,null,null,null,null,null,null,null,null,{"name":"enrolleeRegistration","qid":"19","text":"Enrollee Registration Form","type":"control_head"},{"name":"address","qid":"20","text":"Address","type":"control_address"},null,{"name":"gender","qid":"22","text":"Gender","type":"control_dropdown"},{"name":"phoneNumber23","qid":"23","text":"Phone Number","type":"control_phone"},{"name":"emailAddress","qid":"24","text":"E-mail Address","type":"control_email"},null,{"description":"","name":"firstName","qid":"26","subLabel":"","text":"First Name","type":"control_textbox"},{"description":"","name":"middleName","qid":"27","subLabel":"","text":"Middle Name","type":"control_textbox"},null,{"description":"","name":"employeeId","qid":"29","subLabel":"","text":"Employee ID","type":"control_textbox"},{"description":"","name":"typeOf30","qid":"30","subLabel":"","text":"Type of Plan","type":"control_dropdown"},{"description":"","name":"hospitals","qid":"31","subLabel":"Choose From our Network of Hospitals* (State-Town-Hospital) *","text":"Hospitals","type":"control_dropdown"},null,null,{"name":"divider","qid":"34","type":"control_divider"},{"name":"bspanStyletextdecoration","qid":"35","text":"SPOUSE","type":"control_text"},{"description":"","name":"spousesSurname","qid":"36","subLabel":"","text":"Spouse's Surname","type":"control_textbox"},{"description":"","name":"spousesFirst","qid":"37","subLabel":"","text":"Spouse's First Name","type":"control_textbox"},{"description":"","name":"spousesMiddle","qid":"38","subLabel":"","text":"Spouse's Middle Name","type":"control_textbox"},null,null,{"description":"","name":"spousesPhone","qid":"41","text":"Spouse's Phone Number","type":"control_phone"},{"description":"","name":"spousesDate","qid":"42","text":"Spouse's Date of Birth","type":"control_birthdate"},null,null,{"name":"divider45","qid":"45","type":"control_divider"},{"name":"pStyletextalign46","qid":"46","text":"DEPENDENTS","type":"control_text"},null,{"name":"bStyletextalign","qid":"48","text":"PRINCIPAL","type":"control_text"},{"name":"pStyletextalign","qid":"49","text":"DEPENDENT 1","type":"control_text"},{"description":"","name":"1stDependents","qid":"50","subLabel":"","text":"1st Dependent's Surname","type":"control_textbox"},{"description":"","name":"1stDependents51","qid":"51","subLabel":"","text":"1st DependEnt's First Name","type":"control_textbox"},{"description":"","name":"1stDependents52","qid":"52","subLabel":"","text":"1st Dependent's Middle Name","type":"control_textbox"},null,{"description":"","name":"1stDependents54","qid":"54","text":"1st Dependent's Phone Number","type":"control_phone"},{"description":"","name":"1stDependents55","qid":"55","text":"1st Dependent's Date of Birth","type":"control_birthdate"},null,null,{"description":"","name":"spousesHospitals","qid":"58","subLabel":"Choose From our Network of Hospitals* (State-Town-Hospital) *","text":"Spouse's Hospitals","type":"control_dropdown"},{"name":"ltpStyletextalign59","qid":"59","text":"DEPENDENT 2","type":"control_text"},{"description":"","name":"2ndDependents","qid":"60","subLabel":"","text":"2nd Dependent's Surname","type":"control_textbox"},{"description":"","name":"2ndDependents61","qid":"61","subLabel":"","text":"2nd Dependent's First Name","type":"control_textbox"},{"description":"","name":"2ndDependents62","qid":"62","subLabel":"","text":"2nd Dependent's Middle Name","type":"control_textbox"},null,{"description":"","name":"2ndDependents64","qid":"64","text":"2nd Dependent's Phone Number","type":"control_phone"},{"description":"","name":"2ndDependents65","qid":"65","text":"2nd Dependent's Date of Birth","type":"control_birthdate"},null,null,{"name":"ltpStyletextalign68","qid":"68","text":"DEPENDENT 3","type":"control_text"},{"description":"","name":"3rdDependents","qid":"69","subLabel":"","text":"3rd Dependent's Surname","type":"control_textbox"},{"description":"","name":"3rdDependents70","qid":"70","subLabel":"","text":"3rd Dependent's First Name","type":"control_textbox"},{"description":"","name":"3rdDependents71","qid":"71","subLabel":"","text":"3rd Dependent's Middle Name","type":"control_textbox"},null,{"description":"","name":"3rdDependents73","qid":"73","text":"3rd Dependent's Phone Number","type":"control_phone"},{"description":"","name":"3rdDependents74","qid":"74","text":"3rd Dependent's Date of Birth","type":"control_birthdate"},null,null,{"name":"ltpStyletextalign77","qid":"77","text":"DEPENDENT 4","type":"control_text"},{"description":"","name":"4thDependents","qid":"78","subLabel":"","text":"4th Dependent's Surname","type":"control_textbox"},{"description":"","name":"4thDependents79","qid":"79","subLabel":"","text":"4th Dependent's First Name","type":"control_textbox"},{"description":"","name":"4thDependents80","qid":"80","subLabel":"","text":"4th Dependent's Middle Name","type":"control_textbox"},null,{"description":"","name":"4thDependents82","qid":"82","text":"4th Dependent's Phone Number","type":"control_phone"},{"description":"","name":"4thDependents83","qid":"83","text":"4th Dependent's Date of Birth","type":"control_birthdate"},null,null,{"description":"","name":"byClicking86","qid":"86","text":"By clicking SUBMIT you are agreeing to share your information with Alleanza Health.","type":"control_checkbox"},{"description":"","name":"spousesGender","qid":"87","subLabel":"","text":"Spouse's Gender","type":"control_dropdown"},null,{"description":"","name":"1stDependents89","qid":"89","subLabel":"","text":"1st Dependent's Gender","type":"control_dropdown"},{"description":"","name":"1stDependents90","qid":"90","subLabel":"Choose From our Network of Hospitals* (State-Town-Hospital) *","text":"1st Dependent's Hospitals","type":"control_dropdown"},{"description":"","name":"2ndDependents91","qid":"91","subLabel":"","text":"2nd Dependent's Gender","type":"control_dropdown"},{"description":"","name":"2ndDependents92","qid":"92","subLabel":"Choose From our Network of Hospitals* (State-Town-Hospital) *","text":"2nd Dependent's Hospitals","type":"control_dropdown"},{"description":"","name":"3rdDependents93","qid":"93","subLabel":"","text":"3rd Dependent's Gender","type":"control_dropdown"},{"description":"","name":"3rdDependents94","qid":"94","subLabel":"Choose From our Network of Hospitals* (State-Town-Hospital) *","text":"3rd Dependent's Hospitals","type":"control_dropdown"},{"description":"","name":"4thDependents95","qid":"95","subLabel":"","text":"4th Dependent's Gender","type":"control_dropdown"},{"description":"","name":"4thDependents96","qid":"96","subLabel":"Choose From our Network of Hospitals* (State-Town-Hospital) *","text":"4th Dependent's Hospitals","type":"control_dropdown"},null,{"description":"","name":"companyName","qid":"98","subLabel":"","text":"Company Name","type":"control_textbox"},{"description":"","name":"passport","qid":"99","subLabel":"Select passport photo from your device.","text":"Passport","type":"control_fileupload"},{"description":"","name":"spousesPassport","qid":"100","subLabel":"Select passport photo from your device.","text":"Spouse's Passport","type":"control_fileupload"},{"description":"","name":"1stDependents101","qid":"101","subLabel":"Select passport photo from your device.","text":"1st Dependent's Passport","type":"control_fileupload"},{"description":"","name":"2ndDependents102","qid":"102","subLabel":"Select passport photo from your device.","text":"2nd Dependent's Passport","type":"control_fileupload"},{"description":"","name":"3rdDependents103","qid":"103","subLabel":"Select passport photo from your device.","text":"3rd Dependent's Passport","type":"control_fileupload"},{"description":"","name":"4thDependents104","qid":"104","subLabel":"Select passport photo from your device.","text":"4th Dependent's Passport","type":"control_fileupload"},{"description":"","labelText":"","name":"red5f873c775176e4535887665f8bfa6c3c2ad287990493","qid":"105","text":"Red.5f873c775176e4.53588766.5f8bfa6c3c2ad2.87990493","type":"control_image"},{"description":"","name":"groupOf","qid":"106","text":"Group of Plan","type":"control_radio"}]);
   setTimeout(function() {
JotForm.paymentExtrasOnTheFly([null,null,{"name":"submitForm","qid":"2","text":"Submit Form","type":"control_button"},null,{"name":"surname","qid":"4","text":"Surname","type":"control_textbox"},null,null,null,null,{"name":"dateOf","qid":"9","text":"Date of Birth","type":"control_birthdate"},null,null,null,null,null,null,null,null,null,{"name":"enrolleeRegistration","qid":"19","text":"Enrollee Registration Form","type":"control_head"},{"name":"address","qid":"20","text":"Address","type":"control_address"},null,{"name":"gender","qid":"22","text":"Gender","type":"control_dropdown"},{"name":"phoneNumber23","qid":"23","text":"Phone Number","type":"control_phone"},{"name":"emailAddress","qid":"24","text":"E-mail Address","type":"control_email"},null,{"description":"","name":"firstName","qid":"26","subLabel":"","text":"First Name","type":"control_textbox"},{"description":"","name":"middleName","qid":"27","subLabel":"","text":"Middle Name","type":"control_textbox"},null,{"description":"","name":"employeeId","qid":"29","subLabel":"","text":"Employee ID","type":"control_textbox"},{"description":"","name":"typeOf30","qid":"30","subLabel":"","text":"Type of Plan","type":"control_dropdown"},{"description":"","name":"hospitals","qid":"31","subLabel":"Choose From our Network of Hospitals* (State-Town-Hospital) *","text":"Hospitals","type":"control_dropdown"},null,null,{"name":"divider","qid":"34","type":"control_divider"},{"name":"bspanStyletextdecoration","qid":"35","text":"SPOUSE","type":"control_text"},{"description":"","name":"spousesSurname","qid":"36","subLabel":"","text":"Spouse's Surname","type":"control_textbox"},{"description":"","name":"spousesFirst","qid":"37","subLabel":"","text":"Spouse's First Name","type":"control_textbox"},{"description":"","name":"spousesMiddle","qid":"38","subLabel":"","text":"Spouse's Middle Name","type":"control_textbox"},null,null,{"description":"","name":"spousesPhone","qid":"41","text":"Spouse's Phone Number","type":"control_phone"},{"description":"","name":"spousesDate","qid":"42","text":"Spouse's Date of Birth","type":"control_birthdate"},null,null,{"name":"divider45","qid":"45","type":"control_divider"},{"name":"pStyletextalign46","qid":"46","text":"DEPENDENTS","type":"control_text"},null,{"name":"bStyletextalign","qid":"48","text":"PRINCIPAL","type":"control_text"},{"name":"pStyletextalign","qid":"49","text":"DEPENDENT 1","type":"control_text"},{"description":"","name":"1stDependents","qid":"50","subLabel":"","text":"1st Dependent's Surname","type":"control_textbox"},{"description":"","name":"1stDependents51","qid":"51","subLabel":"","text":"1st DependEnt's First Name","type":"control_textbox"},{"description":"","name":"1stDependents52","qid":"52","subLabel":"","text":"1st Dependent's Middle Name","type":"control_textbox"},null,{"description":"","name":"1stDependents54","qid":"54","text":"1st Dependent's Phone Number","type":"control_phone"},{"description":"","name":"1stDependents55","qid":"55","text":"1st Dependent's Date of Birth","type":"control_birthdate"},null,null,{"description":"","name":"spousesHospitals","qid":"58","subLabel":"Choose From our Network of Hospitals* (State-Town-Hospital) *","text":"Spouse's Hospitals","type":"control_dropdown"},{"name":"ltpStyletextalign59","qid":"59","text":"DEPENDENT 2","type":"control_text"},{"description":"","name":"2ndDependents","qid":"60","subLabel":"","text":"2nd Dependent's Surname","type":"control_textbox"},{"description":"","name":"2ndDependents61","qid":"61","subLabel":"","text":"2nd Dependent's First Name","type":"control_textbox"},{"description":"","name":"2ndDependents62","qid":"62","subLabel":"","text":"2nd Dependent's Middle Name","type":"control_textbox"},null,{"description":"","name":"2ndDependents64","qid":"64","text":"2nd Dependent's Phone Number","type":"control_phone"},{"description":"","name":"2ndDependents65","qid":"65","text":"2nd Dependent's Date of Birth","type":"control_birthdate"},null,null,{"name":"ltpStyletextalign68","qid":"68","text":"DEPENDENT 3","type":"control_text"},{"description":"","name":"3rdDependents","qid":"69","subLabel":"","text":"3rd Dependent's Surname","type":"control_textbox"},{"description":"","name":"3rdDependents70","qid":"70","subLabel":"","text":"3rd Dependent's First Name","type":"control_textbox"},{"description":"","name":"3rdDependents71","qid":"71","subLabel":"","text":"3rd Dependent's Middle Name","type":"control_textbox"},null,{"description":"","name":"3rdDependents73","qid":"73","text":"3rd Dependent's Phone Number","type":"control_phone"},{"description":"","name":"3rdDependents74","qid":"74","text":"3rd Dependent's Date of Birth","type":"control_birthdate"},null,null,{"name":"ltpStyletextalign77","qid":"77","text":"DEPENDENT 4","type":"control_text"},{"description":"","name":"4thDependents","qid":"78","subLabel":"","text":"4th Dependent's Surname","type":"control_textbox"},{"description":"","name":"4thDependents79","qid":"79","subLabel":"","text":"4th Dependent's First Name","type":"control_textbox"},{"description":"","name":"4thDependents80","qid":"80","subLabel":"","text":"4th Dependent's Middle Name","type":"control_textbox"},null,{"description":"","name":"4thDependents82","qid":"82","text":"4th Dependent's Phone Number","type":"control_phone"},{"description":"","name":"4thDependents83","qid":"83","text":"4th Dependent's Date of Birth","type":"control_birthdate"},null,null,{"description":"","name":"byClicking86","qid":"86","text":"By clicking SUBMIT you are agreeing to share your information with Alleanza Health.","type":"control_checkbox"},{"description":"","name":"spousesGender","qid":"87","subLabel":"","text":"Spouse's Gender","type":"control_dropdown"},null,{"description":"","name":"1stDependents89","qid":"89","subLabel":"","text":"1st Dependent's Gender","type":"control_dropdown"},{"description":"","name":"1stDependents90","qid":"90","subLabel":"Choose From our Network of Hospitals* (State-Town-Hospital) *","text":"1st Dependent's Hospitals","type":"control_dropdown"},{"description":"","name":"2ndDependents91","qid":"91","subLabel":"","text":"2nd Dependent's Gender","type":"control_dropdown"},{"description":"","name":"2ndDependents92","qid":"92","subLabel":"Choose From our Network of Hospitals* (State-Town-Hospital) *","text":"2nd Dependent's Hospitals","type":"control_dropdown"},{"description":"","name":"3rdDependents93","qid":"93","subLabel":"","text":"3rd Dependent's Gender","type":"control_dropdown"},{"description":"","name":"3rdDependents94","qid":"94","subLabel":"Choose From our Network of Hospitals* (State-Town-Hospital) *","text":"3rd Dependent's Hospitals","type":"control_dropdown"},{"description":"","name":"4thDependents95","qid":"95","subLabel":"","text":"4th Dependent's Gender","type":"control_dropdown"},{"description":"","name":"4thDependents96","qid":"96","subLabel":"Choose From our Network of Hospitals* (State-Town-Hospital) *","text":"4th Dependent's Hospitals","type":"control_dropdown"},null,{"description":"","name":"companyName","qid":"98","subLabel":"","text":"Company Name","type":"control_textbox"},{"description":"","name":"passport","qid":"99","subLabel":"Select passport photo from your device.","text":"Passport","type":"control_fileupload"},{"description":"","name":"spousesPassport","qid":"100","subLabel":"Select passport photo from your device.","text":"Spouse's Passport","type":"control_fileupload"},{"description":"","name":"1stDependents101","qid":"101","subLabel":"Select passport photo from your device.","text":"1st Dependent's Passport","type":"control_fileupload"},{"description":"","name":"2ndDependents102","qid":"102","subLabel":"Select passport photo from your device.","text":"2nd Dependent's Passport","type":"control_fileupload"},{"description":"","name":"3rdDependents103","qid":"103","subLabel":"Select passport photo from your device.","text":"3rd Dependent's Passport","type":"control_fileupload"},{"description":"","name":"4thDependents104","qid":"104","subLabel":"Select passport photo from your device.","text":"4th Dependent's Passport","type":"control_fileupload"},{"description":"","labelText":"","name":"red5f873c775176e4535887665f8bfa6c3c2ad287990493","qid":"105","text":"Red.5f873c775176e4.53588766.5f8bfa6c3c2ad2.87990493","type":"control_image"},{"description":"","name":"groupOf","qid":"106","text":"Group of Plan","type":"control_radio"}]);}, 20); 
</script>
<link href="https://cdn.jotfor.ms/static/formCss.css?3.3.21109" rel="stylesheet" type="text/css" />
<link type="text/css" rel="stylesheet" href="https://cdn.jotfor.ms/css/styles/nova.css?3.3.21109" />
<link type="text/css" media="print" rel="stylesheet" href="https://cdn.jotfor.ms/css/printForm.css?3.3.21109" />
<link type="text/css" rel="stylesheet" href="https://cdn.jotfor.ms/css/styles/payment/payment_feature.css?3.3.21109" />
<style type="text/css">
    .form-label-left{
        width:150px;
    }
    .form-line{
        padding-top:12px;
        padding-bottom:12px;
    }
    .form-label-right{
        width:150px;
    }
    .form-all{
        width:580px;
        color:#555 !important;
        font-family:"Lucida Grande", "Lucida Sans Unicode", "Lucida Sans", Verdana, sans-serif;
        font-size:14px;
    }
    .form-radio-item label, .form-checkbox-item label, .form-grading-label, .form-header{
        color: false;
    }

</style>

<style type="text/css" id="form-designer-style">
    /* Injected CSS Code */
@import "//www.jotform.com/themes/css/buttons/form-submit-button-blue.css";
.form-all:after {
  content: "";
  display: table;
  clear: both;
}
.form-all {
  font-family: "Lucida Grande", sans-serif;
}
.form-all {
  width: 580px;
  width: 100%;
  max-width: 580px;
}
.form-label-left,
.form-label-right {
  width: 150px;
}
.form-label {
  white-space: normal;
}
.form-label.form-label-auto {
  display: inline-block;
  float: left;
  text-align: left;
  word-break: break-word;
  width: 150px;
}
.form-label-left {
  display: inline-block;
  white-space: normal;
  float: left;
  text-align: left;
}
.form-label-right {
  display: inline-block;
  white-space: normal;
  float: left;
  text-align: right;
}
.form-label-top {
  white-space: normal;
  display: block;
  float: none;
  text-align: left;
}
.form-radio-item label:before {
  top: 0;
}
.form-all {
  font-size: 14px;
}
.form-label {
  font-weight: bold;
}
.form-checkbox-item label,
.form-radio-item label {
  font-weight: normal;
}
.supernova {
  background-color: rgba(255, 255, 255, 0.88);
  background-color: #f5f5f5;
}
.supernova body {
  background-color: transparent;
}
/*
@width30: (unit(@formWidth, px) + 60px);
@width60: (unit(@formWidth, px)+ 120px);
@width90: (unit(@formWidth, px)+ 180px);
*/
/* | */
@media screen and (min-width: 480px) {
  .supernova .form-all {
    border: 1px solid #dcdcdc;
    box-shadow: 0 3px 9px rgba(0, 0, 0, 0.1);
  }
}
/* | */
/* | */
@media screen and (max-width: 480px) {
  .jotform-form .form-all {
    margin: 0;
    width: 100%;
  }
}
/* | */
/* | */
@media screen and (min-width: 480px) and (max-width: 767px) {
  .jotform-form .form-all {
    margin: 0;
    width: 100%;
  }
}
/* | */
/* | */
@media screen and (min-width: 480px) and (max-width: 579px) {
  .jotform-form .form-all {
    margin: 0;
    width: 100%;
  }
}
/* | */
/* | */
@media screen and (min-width: 768px) {
  .jotform-form {
    padding: 60px 0;
  }
}
/* | */
/* | */
@media screen and (max-width: 579px) {
  .jotform-form .form-all {
    margin: 0;
    width: 100%;
  }
}
/* | */
.supernova .form-all,
.form-all {
  background-color: rgba(255, 255, 255, 0.88);
  border: 1px solid transparent;
}
.form-header-group {
  border-color: rgba(230, 230, 230, 0.88);
}
.form-matrix-table tr {
  border-color: rgba(230, 230, 230, 0.88);
}
.form-matrix-table tr:nth-child(2n) {
  background-color: rgba(242, 242, 242, 0.88);
}
.form-all {
  color: #555555;
}
.form-header-group .form-header {
  color: #555555;
}
.form-header-group .form-subHeader {
  color: #6f6f6f;
}
.form-sub-label {
  color: #6f6f6f;
}
.form-label-top,
.form-label-left,
.form-label-right,
.form-html {
  color: #555555;
}
.form-checkbox-item label,
.form-radio-item label {
  color: #6f6f6f;
}
.form-line.form-line-active {
  -webkit-transition-property: all;
  -moz-transition-property: all;
  -ms-transition-property: all;
  -o-transition-property: all;
  transition-property: all;
  -webkit-transition-duration: 0.3s;
  -moz-transition-duration: 0.3s;
  -ms-transition-duration: 0.3s;
  -o-transition-duration: 0.3s;
  transition-duration: 0.3s;
  -webkit-transition-timing-function: ease;
  -moz-transition-timing-function: ease;
  -ms-transition-timing-function: ease;
  -o-transition-timing-function: ease;
  transition-timing-function: ease;
  background-color: rgba(255, 251, 234, 0);
}
/* omer */
.form-radio-item,
.form-checkbox-item {
  padding-bottom: 0px !important;
}
.form-radio-item:last-child,
.form-checkbox-item:last-child {
  padding-bottom: 0;
}
/* omer */
.form-single-column .form-checkbox-item,
.form-single-column .form-radio-item {
  width: 100%;
}
.form-checkbox-item .editor-container div,
.form-radio-item .editor-container div {
  position: relative;
}
.form-checkbox-item .editor-container div:before,
.form-radio-item .editor-container div:before {
  display: inline-block;
  vertical-align: middle;
  box-sizing: border-box;
  left: 0;
  width: 18px;
  height: 18px;
}
.form-checkbox-item,
.form-radio-item {
  padding-left: 2px;
}
.form-checkbox-item input,
.form-radio-item input {
  margin-top: 2px;
}
.supernova {
  height: 100%;
  background-repeat: no-repeat;
  background-attachment: scroll;
  background-position: center top;
  background-attachment: fixed;
  background-size: auto;
  background-size: cover;
}
.supernova {
  background-image: none;
  background-image: url("https://www.jotform.com/uploads/batuhan/form_files/final_20864245705555.5b18e0a95657b9.83368454.jpg");
}
#stage {
  background-image: none;
  background-image: url("https://www.jotform.com/uploads/batuhan/form_files/final_20864245705555.5b18e0a95657b9.83368454.jpg");
}
/* | */
.form-all {
  background-repeat: no-repeat;
  background-attachment: scroll;
  background-position: center top;
}
.form-header-group {
  background-repeat: no-repeat;
  background-attachment: scroll;
  background-position: center top;
}
.form-line {
  margin-top: 12px;
  margin-bottom: 12px;
}
.form-line {
  padding: 0px 36px;
}
.form-all .form-submit-button,
.form-all .form-submit-reset,
.form-all .form-submit-print {
  border-radius: 100px;
}
.form-all .form-sub-label {
  margin-left: 3px;
}
.form-all {
  border-radius: 6px;
}
.form-section:first-child {
  border-radius: 6px 6px 0 0;
}
.form-section:last-child {
  border-radius: 0 0 6px 6px;
}
.form-all .qq-upload-button,
.form-all .form-submit-button,
.form-all .form-submit-reset,
.form-all .form-submit-print {
  font-size: 1em;
  padding: 9px 15px;
  font-family: "Lucida Grande", sans-serif;
  font-size: 14px;
  font-weight: normal;
}
.form-all .form-pagebreak-back,
.form-all .form-pagebreak-next {
  font-size: 1em;
  padding: 9px 15px;
  font-family: "Lucida Grande", sans-serif;
  font-size: 14px;
  font-weight: normal;
}
/*
& when ( @buttonFontType = google ) {
	@import (css) "@{buttonFontLink}";
}
*/
h2.form-header {
  line-height: 1.618em;
  font-size: 1.714em;
}
h2 ~ .form-subHeader {
  line-height: 1.5em;
  font-size: 1.071em;
}
.form-header-group {
  text-align: left;
}
/*.form-dropdown,
.form-radio-item,
.form-checkbox-item,
.form-radio-other-input,
.form-checkbox-other-input,*/
.form-captcha input,
.form-spinner input,
.form-error-message {
  padding: 4px 3px 2px 3px;
}
.form-header-group {
  font-family: "Lucida Grande", sans-serif;
}
.form-section {
  padding: 0px 0px 0px 0px;
}
.form-header-group {
  margin: 12px 36px 12px 36px;
}
.form-header-group {
  padding: 24px 0px 24px 0px;
}
.form-textbox,
.form-textarea {
  padding: 4px 3px 2px 3px;
}
.form-textbox,
.form-textarea,
.form-radio-other-input,
.form-checkbox-other-input,
.form-captcha input,
.form-spinner input {
  background-color: #ffffff;
}
.form-matrix-row-headers,
.form-matrix-column-headers,
.form-matrix-values {
  padding: 4px;
}
.form-dropdown {
  border-color: #cccccc;
}
input.form-dropdown {
    border: #ccc solid 1px;
}
[data-type="control_dropdown"] .form-input,
[data-type="control_dropdown"] .form-input-wide {
  width: 150px;
}
.form-label {
  margin-right: 0px;
  margin-bottom: 0;
}
.form-label {
  font-family: "Lucida Grande", sans-serif;
}
li[data-type="control_image"] div {
  text-align: left;
}
li[data-type="control_image"] img {
  border: none;
  border-width: 0px !important;
  border-style: solid !important;
  border-color: false !important;
}
.form-line-column {
  width: auto;
}
.form-line-error {
  background-color: rgba(255, 255, 255, 0.88);
  box-shadow: inset 0px 3px 11px -7px #ff3200;
}
.form-line-error input:not(#coupon-input),
.form-line-error textarea,
.form-line-error .form-validation-error {
  -webkit-transition-property: none;
  -moz-transition-property: none;
  -ms-transition-property: none;
  -o-transition-property: none;
  transition-property: none;
  -webkit-transition-duration: 0.3s;
  -moz-transition-duration: 0.3s;
  -ms-transition-duration: 0.3s;
  -o-transition-duration: 0.3s;
  transition-duration: 0.3s;
  -webkit-transition-timing-function: ease;
  -moz-transition-timing-function: ease;
  -ms-transition-timing-function: ease;
  -o-transition-timing-function: ease;
  transition-timing-function: ease;
  border: 1px solid #fff4f4;
  box-shadow: 0 0 3px #fff4f4;
}
.form-line-error .form-error-message {
  margin: 0;
  position: absolute;
  color: #fff;
  display: inline-block;
  right: 0;
  font-size: 12px;
  position: absolute!important;
  box-shadow: none;
  top: 0px;
  color: #FFF;
  background: #ff3200;
  padding: 0px 5px;
  bottom: auto;
  border-radius: 0;
  box-shadow: 0px 2px 4px rgba(102, 102, 102, 0.5);
}
.form-line-error .form-error-message img,
.form-line-error .form-error-message .form-error-arrow {
  display: none;
}
.ie-8 .form-all {
  margin-top: auto;
  margin-top: initial;
}
.ie-8 .form-all:before {
  display: none;
}
[data-type="control_clear"] {
  display: none;
}
/* | */
@media screen and (max-width: 480px), screen and (max-device-width: 767px) and (orientation: portrait), screen and (max-device-width: 415px) and (orientation: landscape) {
  .testOne {
    letter-spacing: 0;
  }
  .form-all {
    border: 0;
    max-width: initial;
  }
  .form-sub-label-container {
    width: 100%;
    margin: 0;
    margin-right: 0;
    float: left;
    box-sizing: border-box;
  }
  span.form-sub-label-container + span.form-sub-label-container {
    margin-right: 0;
  }
  .form-sub-label {
    white-space: normal;
  }
  .form-address-table td,
  .form-address-table th {
    padding: 0 1px 10px;
  }
  .form-submit-button,
  .form-submit-print,
  .form-submit-reset {
    width: 100%;
    margin-left: 0!important;
  }
  div[id*=at_] {
    font-size: 14px;
    font-weight: 700;
    height: 8px;
    margin-top: 6px;
  }
  .showAutoCalendar {
    width: 20px;
  }
  img.form-image {
    max-width: 100%;
    height: auto;
  }
  .form-matrix-row-headers {
    width: 100%;
    word-break: break-all;
    min-width: 80px;
  }
  .form-collapse-table,
  .form-header-group {
    margin: 0;
  }
  .form-collapse-table {
    height: 100%;
    display: inline-block;
    width: 100%;
  }
  .form-collapse-hidden {
    display: none !important;
  }
  .form-input {
    width: 100%;
  }
  .form-label {
    width: 100% !important;
  }
  .form-label-left,
  .form-label-right {
    display: block;
    float: none;
    text-align: left;
    width: auto!important;
  }
  .form-line,
  .form-line.form-line-column {
    padding: 2% 5%;
    box-sizing: border-box;
  }
  input[type=text],
  input[type=email],
  input[type=tel],
  textarea {
    width: 100%;
    box-sizing: border-box;
    max-width: initial !important;
  }
  .form-radio-other-input,
  .form-checkbox-other-input {
    max-width: 55% !important;
  }
  .form-dropdown,
  .form-textarea,
  .form-textbox {
    width: 100%!important;
    box-sizing: border-box;
  }
  .form-input,
  .form-input-wide,
  .form-textarea,
  .form-textbox,
  .form-dropdown {
    max-width: initial!important;
  }
  .form-checkbox-item:not(#foo),
  .form-radio-item:not(#foo) {
    width: 100%;
  }
  .form-address-city,
  .form-address-line,
  .form-address-postal,
  .form-address-state,
  .form-address-table,
  .form-address-table .form-sub-label-container,
  .form-address-table select,
  .form-input {
    width: 100%;
  }
  div.form-header-group {
    padding: 24px 0px !important;
    margin: 0 12px 2% !important;
    margin-left: 5%!important;
    margin-right: 5%!important;
    box-sizing: border-box;
  }
  div.form-header-group.hasImage img {
    max-width: 100%;
  }
  [data-type="control_button"] {
    margin-bottom: 0 !important;
  }
  [data-type=control_fullname] .form-sub-label-container {
    width: 48%;
  }
  [data-type=control_fullname] .form-sub-label-container:first-child {
    margin-right: 4%;
  }
  [data-type=control_phone] .form-sub-label-container {
    width: 65%;
    margin-right: 0;
    margin-left: 0;
    float: left;
  }
  [data-type=control_phone] .form-sub-label-container:first-child {
    width: 31%;
    margin-right: 4%;
  }
  [data-type=control_datetime] .allowTime-container {
    width: 100%;
  }
  [data-type=control_datetime] .allowTime-container .form-sub-label-container {
    width: 24%!important;
    margin-left: 6%;
    margin-right: 0;
  }
  [data-type=control_datetime] .allowTime-container .form-sub-label-container:first-child {
    margin-left: 0;
  }
  [data-type=control_datetime] span + span + span > span:first-child {
    display: block;
    width: 100% !important;
  }
  [data-type=control_birthdate] .form-sub-label-container,
  [data-type=control_time] .form-sub-label-container {
    width: 27.3%!important;
    margin-right: 6% !important;
  }
  [data-type=control_time] .form-sub-label-container:last-child {
    width: 33.3%!important;
    margin-right: 0 !important;
  }
  .form-pagebreak-back-container,
  .form-pagebreak-next-container {
    min-height: 1px;
    width: 50% !important;
  }
  .form-pagebreak-back,
  .form-pagebreak-next,
  .form-product-item.hover-product-item {
    width: 100%;
  }
  .form-pagebreak-back-container {
    padding: 0;
    text-align: right;
  }
  .form-pagebreak-next-container {
    padding: 0;
    text-align: left;
  }
  .form-pagebreak {
    margin: 0 auto;
  }
  .form-buttons-wrapper {
    margin: 0!important;
    margin-left: 0!important;
  }
  .form-buttons-wrapper button {
    width: 100%;
  }
  .form-buttons-wrapper .form-submit-print {
    margin: 0 !important;
  }
  table {
    width: 100%!important;
    max-width: initial!important;
  }
  table td + td {
    padding-left: 3%;
  }
  .form-checkbox-item,
  .form-radio-item {
    white-space: normal!important;
  }
  .form-checkbox-item input,
  .form-radio-item input {
    width: auto;
  }
  .form-collapse-table {
    margin: 0 5%;
    display: block;
    zoom: 1;
    width: auto;
  }
  .form-collapse-table:before,
  .form-collapse-table:after {
    display: table;
    content: '';
    line-height: 0;
  }
  .form-collapse-table:after {
    clear: both;
  }
  .fb-like-box {
    width: 98% !important;
  }
  .form-error-message {
    clear: both;
    bottom: -10px;
  }
  .date-separate,
  .phone-separate {
    display: none;
  }
  .custom-field-frame,
  .direct-embed-widgets,
  .signature-pad-wrapper {
    width: 100% !important;
  }
}
/* | */

/*__INSPECT_SEPERATOR__*/
/*---------------------
Theme: Generic Theme
Author: Elton Cris - idarktech@jotform.com
www.jotform.com
----------------------*/
.form-all {
    -moz-box-sizing : border-box;
    -webkit-box-sizing : border-box;
    box-sizing : border-box;
}

[data-type="control_head"] {
    padding-bottom : 20px;
}

/*responsive fields*/
[data-type="control_textbox"] .form-textbox, 
[data-type="control_fullname"] .form-textbox,
[data-type="control_email"] .form-textbox,
[data-type="control_textarea"] .form-textarea, 
[data-type="control_dropdown"] .form-dropdown {
    width : 100% !important;
    max-width : none !important;
}

.form-textbox, .form-textarea, .form-dropdown {
    max-width : none !important;
    box-shadow : none;
    outline : none;
    box-sizing : border-box;
    -webkit-box-sizing : border-box;
    -moz-box-sizing : border-box;
    font-family : inherit;
}

[data-type="control_dropdown"] .form-input, 
[data-type="control_dropdown"] .form-input-wide {
    width : 100%;
}

/*input focus*/
.form-line-active input:focus, .form-line-active textarea:focus, .form-line-active select:focus {
    box-shadow : none;
}

/*reset error*/
.form-line-error {
    box-shadow : none;
}

/*input error*/
.form-line-error input:not(#coupon-input), .form-line-error textarea, .form-line-error select, .form-line-error .form-validation-error {
    border : 1px solid #e15353 !important;
    box-shadow : none !important;
}

.form-line-active {
    color : inherit !important;
}

/*responsive content -wide or shrink*/
.form-label {
    width : 35% !important;
    box-sizing : border-box;
    -webkit-box-sizing : border-box;
    -moz-box-sizing : border-box;
}

.form-label-top {
    width : 100% !important;
}

.form-line {
    box-sizing : border-box;
    -webkit-box-sizing : border-box;
    -moz-box-sizing : border-box;
    width : 100%;
}

.form-checkbox-other-input {
    width : 80% !important;
}

.form-input {
    width : 65% !important;
    max-width : none !important;
}

.form-input-wide {
    max-width : none !important;
    display : inline-block;
    width : 100%;
}

/*single fields with sublabels*/
[data-type="control_textbox"] .form-input-wide .form-sub-label-container, 
[data-type="control_fullname"] .form-input-wide .form-sub-label-container,
[data-type="control_email"] .form-input-wide .form-sub-label-container,
[data-type="control_textarea"] .form-input-wide .form-sub-label-container, 
[data-type="control_dropdown"] .form-input-wide .form-sub-label-container,
[data-type="control_textbox"] .form-input .form-sub-label-container, 
[data-type="control_fullname"] .form-input .form-sub-label-container,
[data-type="control_email"] .form-input .form-sub-label-container,
[data-type="control_textarea"] .form-input .form-sub-label-container, 
[data-type="control_dropdown"] .form-input .form-sub-label-container {
    width : 100%;
    max-width : none !important;
}

[data-type="control_dropdown"] .form-input-wide {
    width : 100%;
}

/*responsive full name*/
[data-type="control_fullname"] .form-sub-label-container {
    width : 50% !important;
    margin : 0;
    float : left;
    box-sizing : border-box;
}

[data-type="control_fullname"] .form-label + div .form-sub-label-container {
    display : inline-block;
    padding-right : 5px;
}

[data-type="control_fullname"] .form-label + div .form-sub-label-container + .form-sub-label-container {
    margin-right : 0;
    padding-right : 0;
    padding-left : 5px;
}

[data-type="control_fullname"] .form-label + div .form-sub-label-container + .form-sub-label-container {
    margin-right : 0;
    padding-right : 0;
    padding-left : 5px;
}

[data-type="control_fullname"] .form-label + div .form-sub-label-container + .form-sub-label-container + .form-sub-label-container {
    padding-left : 0;
    padding-right : 5px;
}

[data-type="control_fullname"] .form-label + div .form-sub-label-container + .form-sub-label-container + .form-sub-label-container + .form-sub-label-container {
    padding-left : 5px;
    padding-right : 0;
}

[data-type="control_fullname"] .form-label + div .form-sub-label-container + .form-sub-label-container  + .form-sub-label-container + .form-sub-label-container + .form-sub-label-container {
    padding-right : 5px;
    padding-left : 0;
}

#sublabel_prefix, #sublabel_first, #sublabel_middle {
    /*margin-bottom : 10px;
    */;
}

/*remove sepatators on date and phone*/
.phone-separate, .date-separate {
    display : none;
}

/*responsive phone fields*/
[data-type="control_phone"] input[name$="[area]"] {
    width : 100%;
}

[data-type="control_phone"] input[name$="[phone]"] {
    width : 100%;
}

[data-type="control_phone"] input[name$="[full]"] {
    width : 100%;
}

[data-type="control_phone"] .form-sub-label-container {
    width : 40%;
    float : left;
    box-sizing : border-box;
    margin-right : 0;
    padding-right : 12px;
}

/* responsive date time field */
[data-type="control_datetime"] .form-textbox,
[data-type="control_datetime"] .form-dropdown {
    width : 100%;
}

[data-type="control_datetime"] .form-sub-label-container {
    width : 28%;
    padding-left : 4px;
    box-sizing : border-box;
    margin-right : 0;
}

[data-type="control_datetime"] .form-sub-label-container:first-child {
    padding-left : 0;
}

[data-type="control_datetime"] .form-sub-label-container:first-child + .form-sub-label-container + .form-sub-label-container {
    padding-right : 0;
}

[data-type="control_datetime"] .form-sub-label-container:last-child {
    width : auto !important;
}

.allowTime-container .form-sub-label-container:last-child {
    width : 20% !important;
}

span.allowTime-container {
    width : 80%;
    padding-top : 14px;
}

.allowTime-container span.form-sub-label-container {
    width : 35%;
}

span.allowTime-container .form-dropdown {
    width : 100%;
}

span.allowTime-container > span:first-child {
    display : none;
}

span.allowTime-container > span:first-child + span {
    padding-left : 0;
}

.showAutoCalendar + label {
    display : none;
}

span.allowTime-container + span {
    padding-top : 14px;
}

/*calendar lite mode*/
[data-type="control_datetime"] div[style*="none"] + .form-sub-label-container {
    width : 84%;
    padding-left : 0;
}

/*responsive phone field*/
[data-type="control_phone"] .form-sub-label-container + .form-sub-label-container {
    width : 60%;
    margin-right : 0;
    padding-right : 0;
    padding-left : 12px;
}

/*responsive full address fields*/
.form-address-city, .form-address-line, .form-address-postal, 
.form-address-state, .form-address-table, 
.form-address-table .form-sub-label-container, .form-address-table select {
    width : 100%;
    max-width : 100%;
}

[data-type="control_address"] input[name$="[city]"],
[data-type="control_address"] input[name$="[postal]"] {
    width : 90% !important;
}

[data-type="control_address"] input[name$="[area]"] {
    width : 60%;
}

/*reset submit button*/
[data-type="control_button"] {
    background : transparent !important;
}

.form-submit-button,
.form-submit-reset,
.form-submit-print {
    outline : none;
}

/*remove other checkbox*/
.form-checkbox-other, 
.form-radio-other {
    visibility : hidden !important;
}

/*shruken fields*/
.form-line-column {
    width : 50%;
}

.form-line-column .form-label-top {
    width : 100% !important;
}

/*fix form builder display*/
div#stage.form-all {
    max-width : none !important;
    margin-right : 0;
}

div#stage .form-input {
    width : 64% !important;
}

/*remove first pagebreak back button*/
.form-all .page-section:first-child .form-pagebreak .form-pagebreak-back-container {
    display : none !important;
}

/* responsive pagebreak */
.form-pagebreak-back-container {
    width : 50% !important;
    text-align : left;
    box-sizing : border-box;
    -webkit-box-sizing : border-box;
    float : left;
}

.form-pagebreak-next-container {
    width : 50% !important;
    text-align : right;
    box-sizing : border-box;
    -webkit-box-sizing : border-box;
    float : left;
}

/* radio-checkbox button make border 1px */
.form-radio-item:not(#foo) label:after,
.form-radio-item:not(#foo) label:before {
    border-radius : 50%;
}

.form-checkbox-item:not(#foo) label:after,
.form-checkbox-item:not(#foo) label:before {
    border-radius : 0;
}

.form-radio-item:not(#foo) label:before,
.form-checkbox-item:not(#foo) label:before {
    border-width : 1px;
}

/*responsive credit card on payment fields*/
table td + td {
    padding-left : 0;
}

.form-address-table {
    width : 100%;
}

[data-type="control_stripe"] .form-address-table,
[data-type="control_stripe"] .form-address-table .form-textbox,
[data-type="control_authnet"] .form-address-table,
[data-type="control_authnet"] .form-address-table .form-textbox,
#creditCardTable.form-address-table,
#creditCardTable.form-address-table .form-textbox {
    max-width : none;
}

[data-type="control_stripe"] .form-address-table td:last-child .form-sub-label-container,
[data-type="control_authnet"] .form-address-table td:last-child .form-sub-label-container,
#creditCardTable.form-address-table td:last-child .form-sub-label-container {
    margin-left : 0;
    white-space : normal;
}

[data-type="control_stripe"] .form-address-table td .form-sub-label-container,
[data-type="control_authnet"] .form-address-table td .form-sub-label-container,
#creditCardTable.form-address-table td .form-sub-label-container {
    width : 100%;
}

[data-type="control_stripe"] .form-address-table .form-textbox,
[data-type="control_stripe"] .form-address-table .form-dropdown,
[data-type="control_authnet"] .form-address-table .form-textbox,
[data-type="control_authnet"] .form-address-table .form-dropdown,
#creditCardTable.form-address-table .form-textbox,
#creditCardTable.form-address-table .form-dropdown {
    width : 100%;
    visibility : visible;
}

[data-type="control_stripe"] .form-address-table tbody > tr:first-child + tr td:first-child span,
[data-type="control_authnet"] .form-address-table tbody > tr:first-child + tr td:first-child span,
#creditCardTable.form-address-table tbody > tr:first-child + tr td:first-child span {
    margin : 0;
    padding-right : 6px;
    box-sizing : border-box;
    -webkit-box-sizing : border-box;
}

[data-type="control_stripe"] .form-address-table tbody > tr:first-child + tr td:first-child + td span,
[data-type="control_authnet"] .form-address-table tbody > tr:first-child + tr td:first-child + td span,
#creditCardTable.form-address-table tbody > tr:first-child + tr td:first-child + td span {
    margin : 0;
    padding-left : 6px;
    box-sizing : border-box;
    -webkit-box-sizing : border-box;
}

[data-type="control_stripe"] .form-address-table tbody > tr:first-child + tr +tr td:first-child span,
[data-type="control_stripe"] .form-address-table tbody > tr:first-child + tr +tr+tr td:first-child span,
[data-type="control_authnet"] .form-address-table tbody > tr:first-child + tr +tr td:first-child span,
[data-type="control_authnet"] .form-address-table tbody > tr:first-child + tr +tr+tr td:first-child span,
#creditCardTable.form-address-table tbody > tr:first-child + tr +tr td:first-child span,
#creditCardTable.form-address-table tbody > tr:first-child + tr +tr+tr td:first-child span {
    margin : 0;
    padding-right : 6px;
    width : 50% !important;
    visibility : hidden;
    float : left;
    box-sizing : border-box;
    -webkit-box-sizing : border-box;
}

[data-type="control_stripe"] .form-address-table tbody > tr:first-child + tr +tr td:first-child span + span,
[data-type="control_stripe"] .form-address-table tbody > tr:first-child + tr +tr+tr td:first-child span + span,
[data-type="control_authnet"] .form-address-table tbody > tr:first-child + tr +tr td:first-child span + span,
[data-type="control_authnet"] .form-address-table tbody > tr:first-child + tr +tr+tr td:first-child span + span,
#creditCardTable.form-address-table tbody > tr:first-child + tr +tr td:first-child span + span,
#creditCardTable.form-address-table tbody > tr:first-child + tr +tr+tr td:first-child span + span {
    margin : 0;
    padding-top : 0 !important;
    padding-right : 0;
    padding-left : 6px;
    width : 50% !important;
    box-sizing : border-box;
    -webkit-box-sizing : border-box;
}

.cc_ccv {
    width : 100% !important;
}

[data-type="control_stripe"] .form-address-table .form-sub-label,
[data-type="control_authnet"] .form-address-table .form-sub-label,
#creditCardTable.form-address-table .form-sub-label {
    visibility : visible;
}

/*cc fix city state, country */
[data-type="control_stripe"] .form-address-table td[width="50%"]>span:first-child,
[data-type="control_authnet"] .form-address-table td[width="50%"]>span:first-child,
#creditCardTable.form-address-table td[width="50%"]>span:first-child {
    box-sizing : border-box;
    padding-right : 7px;
}

[data-type="control_stripe"] .form-address-table td[width="50%"] + td >span:first-child,
[data-type="control_authnet"] .form-address-table td[width="50%"] + td >span:first-child,
#creditCardTable.form-address-table td[width="50%"] + td >span:first-child {
    box-sizing : border-box;
    padding-left : 7px;
}

[data-type="control_stripe"] .form-address-table td[width="50%"] + td[width="50%"] >span:first-child,
[data-type="control_authnet"] .form-address-table td[width="50%"] + td[width="50%"] >span:first-child,
#creditCardTable.form-address-table td[width="50%"] + td[width="50%"] >span:first-child {
    box-sizing : border-box;
    padding-right : 0;
}

.hover-product-item:hover {
    color : inherit;
}

/*fix for braintree cc styling*/
[data-type="control_braintree"] .form-sub-label-container {
    width : 100% !important;
    padding : 4px;
    box-sizing : border-box;
}

[data-type="control_braintree"] .form-textbox {
    width : 100%;
}

.braintree-hosted-fields {
    width : 100% !important;
    box-sizing : border-box;
    min-height : 28px;
}

/*remove bottom spacing on CC section*/
.form-address-table tbody tr + tr + tr td {
    padding-bottom : 0;
}

@media screen and (max-width:768px){
    .form-all {
        margin : 0 auto !important;
        width : 100% !important;
    }

    [data-type=control_fullname] .form-sub-label-container:first-child {
        margin-right : 0;
    }

}

@media screen and (max-width:480px){
    .jotform-form {
        padding : 0;
    }

    .form-input {
        width : 100% !important;
    }

    .form-label {
        width : 100% !important;
        float : none !important;
    }

    .form-line-column {
        width : 100% !important;
    }

    div.form-header-group {
        margin : 0 !important;
        padding : 24px 20px !important;
    }

    [data-type="control_datetime"] .form-sub-label-container {
        float : left;
    }

    [data-type=control_fullname] .form-sub-label-container:first-child {
        margin-right : 0;
    }

}

/*******NEW responsive tableless address field ******/
[data-type="control_address"] .form-address-line input {
    width : 100%;
}

[data-type="control_address"] .form-sub-label-container {
    margin : 0;
}

[data-type="control_address"] .form-address-table 
.form-address-line-wrapper + 
.form-address-line-wrapper +
.form-address-line-wrapper {
    width : 100%;
}

[data-type="control_address"] .form-address-table 
.form-address-line-wrapper + 
.form-address-line-wrapper +
.form-address-line-wrapper .form-address-line {
    width : 50%;
    float : left;
    display : inline-block;
    box-sizing : border-box;
}

.form-address-city-line,
.form-address-zip-line {
    padding-right : 4px;
}

.form-address-state-line,
.form-address-country-line {
    padding-left : 4px;
}

[data-type="control_address"] .form-address-table 
.form-address-line-wrapper + 
.form-address-line-wrapper +
.form-address-line-wrapper +
.form-address-line-wrapper {
    width : 100%;
}

[data-type="control_address"] .form-address-table 
.form-address-line-wrapper + 
.form-address-line-wrapper +
.form-address-line-wrapper +
.form-address-line-wrapper .form-address-line {
    width : 50%;
    float : left;
    box-sizing : border-box;
}


    /* Injected CSS Code */
</style>

<form class="jotform-form" action="https://submit.jotform.com/submit/202932287096562/" method="post" enctype="multipart/form-data" name="form_202932287096562" id="202932287096562" accept-charset="utf-8" autocomplete="on">
  <input type="hidden" name="formID" value="202932287096562" />
  <input type="hidden" id="JWTContainer" value="" />
  <input type="hidden" id="cardinalOrderNumber" value="" />
  <div role="main" class="form-all">
    <ul class="form-section page-section">
      <li class="form-line" data-type="control_image" id="id_105">
        <div id="cid_105" class="form-input-wide">
          <div style="text-align:center">
            <img alt="" class="form-image" style="border:0" src="./Red-logo.png" height="212px" width="508px" data-component="image" />
          </div>
        </div>
      </li>
      <li id="cid_19" class="form-input-wide" data-type="control_head">
        <div class="form-header-group  header-default">
          <div class="header-text httal htvam">
            <h2 id="header_19" class="form-header" data-component="header">
              Enrollee Registration Form
            </h2>
            <div id="subHeader_19" class="form-subHeader">
              Fill the form below indicating indicating your personal details, preferred plan and provider. We will get back soon to you for more updates.
            </div>
          </div>
        </div>
      </li>
      <li class="form-line" data-type="control_text" id="id_48">
        <div id="cid_48" class="form-input-wide">
          <div id="text_48" class="form-html" data-component="text">
            <p style="text-align: center;"><strong style="text-align: center;"><span style="font-size: 18pt; color: #0000ff;"><strong><strong>PRINCIPAL</strong></strong></span></strong></p>
          </div>
        </div>
      </li>
      <li class="form-line jf-required" data-type="control_textbox" id="id_98">
        <label class="form-label form-label-left form-label-auto" id="label_98" for="input_98">
          Company Name
          <span class="form-required">
            *
          </span>
        </label>
        <div id="cid_98" class="form-input jf-required">
          <input type="text" id="input_98" name="q98_companyName" data-type="input-textbox" class="form-readonly form-textbox validate[required]" size="20" value="<?php echo $cmpvalu;?>" tabindex="-1" data-component="textbox" aria-labelledby="label_98" readonly="" required="" />
        </div>
      </li>
      <li class="form-line jf-required" data-type="control_textbox" id="id_4">
        <label class="form-label form-label-left form-label-auto" id="label_4" for="input_4">
          Surname
          <span class="form-required">
            *
          </span>
        </label>
        <div id="cid_4" class="form-input jf-required">
          <input type="text" id="input_4" name="q4_surname" data-type="input-textbox" class="form-textbox validate[required]" size="30" value="" placeholder=" " data-component="textbox" aria-labelledby="label_4" required="" />
        </div>
      </li>
      <li class="form-line jf-required" data-type="control_textbox" id="id_26">
        <label class="form-label form-label-left form-label-auto" id="label_26" for="input_26">
          First Name
          <span class="form-required">
            *
          </span>
        </label>
        <div id="cid_26" class="form-input jf-required">
          <input type="text" id="input_26" name="q26_firstName" data-type="input-textbox" class="form-textbox validate[required]" size="30" value="" placeholder=" " data-component="textbox" aria-labelledby="label_26" required="" />
        </div>
      </li>
      <li class="form-line" data-type="control_textbox" id="id_27">
        <label class="form-label form-label-left form-label-auto" id="label_27" for="input_27">
          Middle Name
        </label>
        <div id="cid_27" class="form-input">
          <input type="text" id="input_27" name="q27_middleName" data-type="input-textbox" class="form-textbox" size="30" value="" placeholder=" " data-component="textbox" aria-labelledby="label_27"/>
        </div>
      </li>
      <li class="form-line jf-required" data-type="control_dropdown" id="id_22">
        <label class="form-label form-label-left form-label-auto" id="label_22" for="input_22">
          Gender
          <span class="form-required">
            *
          </span>
        </label>
        <div id="cid_22" class="form-input jf-required">
          <select class="form-dropdown validate[required]" id="input_22" name="q22_gender" style="width:150px" data-component="dropdown" required="" aria-labelledby="label_22">
            <option value="">  </option>
            <option value="Male"> Male </option>
            <option value="Female"> Female </option>
            <option value="Not willing to Disclose"> Not willing to Disclose </option>
          </select>
        </div>
      </li>
      <li class="form-line jf-required" data-type="control_phone" id="id_23" data-compound-hint=",">
        <label class="form-label form-label-left form-label-auto" id="label_23" for="input_23_area">
          Phone Number
          <span class="form-required">
            *
          </span>
        </label>
        <div id="cid_23" class="form-input jf-required">
          <div data-wrapper-react="true">
            
            <span class="form-sub-label-container" style="vertical-align:top" data-input-type="phone">
              <input type="tel" id="input_23_phone" name="q23_phoneNumber23[phone]" class="form-textbox validate[required]" value="" data-component="phone" aria-labelledby="label_23 sublabel_23_phone" required="" />
              <label class="form-sub-label" for="input_23_phone" id="sublabel_23_phone" style="width:150px" style="min-height:13px" aria-hidden="false"> Phone Number </label>
            </span>
          </div>
        </div>
      </li>
      <li class="form-line jf-required" data-type="control_birthdate" id="id_9">
        <label class="form-label form-label-left form-label-auto" id="label_9" for="input_9">
          Date of Birth
          <span class="form-required">
            *
          </span>
        </label>
        <div id="cid_9" class="form-input jf-required">
          <div data-wrapper-react="true">
            <span class="form-sub-label-container" style="vertical-align:top">
              <select name="q9_dateOf[day]" id="input_9_day" class="form-dropdown validate[required]" data-component="birthdate-day" aria-labelledby="label_9 sublabel_9_day">
                <option>  </option>
                <option value="1"> 1 </option>
                <option value="2"> 2 </option>
                <option value="3"> 3 </option>
                <option value="4"> 4 </option>
                <option value="5"> 5 </option>
                <option value="6"> 6 </option>
                <option value="7"> 7 </option>
                <option value="8"> 8 </option>
                <option value="9"> 9 </option>
                <option value="10"> 10 </option>
                <option value="11"> 11 </option>
                <option value="12"> 12 </option>
                <option value="13"> 13 </option>
                <option value="14"> 14 </option>
                <option value="15"> 15 </option>
                <option value="16"> 16 </option>
                <option value="17"> 17 </option>
                <option value="18"> 18 </option>
                <option value="19"> 19 </option>
                <option value="20"> 20 </option>
                <option value="21"> 21 </option>
                <option value="22"> 22 </option>
                <option value="23"> 23 </option>
                <option value="24"> 24 </option>
                <option value="25"> 25 </option>
                <option value="26"> 26 </option>
                <option value="27"> 27 </option>
                <option value="28"> 28 </option>
                <option value="29"> 29 </option>
                <option value="30"> 30 </option>
                <option value="31"> 31 </option>
              </select>
              <label class="form-sub-label" for="input_9_day" id="sublabel_9_day" style="min-height:13px" aria-hidden="false"> Day </label>
            </span>
            <span class="form-sub-label-container" style="vertical-align:top">
              <select name="q9_dateOf[month]" id="input_9_month" class="form-dropdown validate[required]" data-component="birthdate-month" aria-labelledby="label_9 sublabel_9_month">
                <option>  </option>
                <option value="January"> January </option>
                <option value="February"> February </option>
                <option value="March"> March </option>
                <option value="April"> April </option>
                <option value="May"> May </option>
                <option value="June"> June </option>
                <option value="July"> July </option>
                <option value="August"> August </option>
                <option value="September"> September </option>
                <option value="October"> October </option>
                <option value="November"> November </option>
                <option value="December"> December </option>
              </select>
              <label class="form-sub-label" for="input_9_month" id="sublabel_9_month" style="min-height:13px" aria-hidden="false"> Month </label>
            </span>
            <span class="form-sub-label-container" style="vertical-align:top">
              <select name="q9_dateOf[year]" id="input_9_year" class="form-dropdown validate[required]" data-component="birthdate-year" aria-labelledby="label_9 sublabel_9_year">
                <option>  </option>
                <option value="2022"> 2022 </option>
                <option value="2021"> 2021 </option>
                <option value="2020"> 2020 </option>
                <option value="2019"> 2019 </option>
                <option value="2018"> 2018 </option>
                <option value="2017"> 2017 </option>
                <option value="2016"> 2016 </option>
                <option value="2015"> 2015 </option>
                <option value="2014"> 2014 </option>
                <option value="2013"> 2013 </option>
                <option value="2012"> 2012 </option>
                <option value="2011"> 2011 </option>
                <option value="2010"> 2010 </option>
                <option value="2009"> 2009 </option>
                <option value="2008"> 2008 </option>
                <option value="2007"> 2007 </option>
                <option value="2006"> 2006 </option>
                <option value="2005"> 2005 </option>
                <option value="2004"> 2004 </option>
                <option value="2003"> 2003 </option>
                <option value="2002"> 2002 </option>
                <option value="2001"> 2001 </option>
                <option value="2000"> 2000 </option>
                <option value="1999"> 1999 </option>
                <option value="1998"> 1998 </option>
                <option value="1997"> 1997 </option>
                <option value="1996"> 1996 </option>
                <option value="1995"> 1995 </option>
                <option value="1994"> 1994 </option>
                <option value="1993"> 1993 </option>
                <option value="1992"> 1992 </option>
                <option value="1991"> 1991 </option>
                <option value="1990"> 1990 </option>
                <option value="1989"> 1989 </option>
                <option value="1988"> 1988 </option>
                <option value="1987"> 1987 </option>
                <option value="1986"> 1986 </option>
                <option value="1985"> 1985 </option>
                <option value="1984"> 1984 </option>
                <option value="1983"> 1983 </option>
                <option value="1982"> 1982 </option>
                <option value="1981"> 1981 </option>
                <option value="1980"> 1980 </option>
                <option value="1979"> 1979 </option>
                <option value="1978"> 1978 </option>
                <option value="1977"> 1977 </option>
                <option value="1976"> 1976 </option>
                <option value="1975"> 1975 </option>
                <option value="1974"> 1974 </option>
                <option value="1973"> 1973 </option>
                <option value="1972"> 1972 </option>
                <option value="1971"> 1971 </option>
                <option value="1970"> 1970 </option>
                <option value="1969"> 1969 </option>
                <option value="1968"> 1968 </option>
                <option value="1967"> 1967 </option>
                <option value="1966"> 1966 </option>
                <option value="1965"> 1965 </option>
                <option value="1964"> 1964 </option>
                <option value="1963"> 1963 </option>
                <option value="1962"> 1962 </option>
                <option value="1961"> 1961 </option>
                <option value="1960"> 1960 </option>
                <option value="1959"> 1959 </option>
                <option value="1958"> 1958 </option>
                <option value="1957"> 1957 </option>
                <option value="1956"> 1956 </option>
                <option value="1955"> 1955 </option>
                <option value="1954"> 1954 </option>
                <option value="1953"> 1953 </option>
                <option value="1952"> 1952 </option>
                <option value="1951"> 1951 </option>
                <option value="1950"> 1950 </option>
                <option value="1949"> 1949 </option>
                <option value="1948"> 1948 </option>
                <option value="1947"> 1947 </option>
                <option value="1946"> 1946 </option>
                <option value="1945"> 1945 </option>
                <option value="1944"> 1944 </option>
                <option value="1943"> 1943 </option>
                <option value="1942"> 1942 </option>
                <option value="1941"> 1941 </option>
                <option value="1940"> 1940 </option>
                <option value="1939"> 1939 </option>
                <option value="1938"> 1938 </option>
                <option value="1937"> 1937 </option>
                <option value="1936"> 1936 </option>
                <option value="1935"> 1935 </option>
                <option value="1934"> 1934 </option>
                <option value="1933"> 1933 </option>
                <option value="1932"> 1932 </option>
                <option value="1931"> 1931 </option>
                <option value="1930"> 1930 </option>
                <option value="1929"> 1929 </option>
                <option value="1928"> 1928 </option>
                <option value="1927"> 1927 </option>
                <option value="1926"> 1926 </option>
                <option value="1925"> 1925 </option>
                <option value="1924"> 1924 </option>
                <option value="1923"> 1923 </option>
                <option value="1922"> 1922 </option>
                <option value="1921"> 1921 </option>
                <option value="1920"> 1920 </option>
              </select>
              <label class="form-sub-label" for="input_9_year" id="sublabel_9_year" style="min-height:13px" aria-hidden="false"> Year </label>
            </span>
          </div>
        </div>
      </li>
      <li class="form-line jf-required" data-type="control_dropdown" id="id_30">
        <label class="form-label form-label-left form-label-auto" id="label_30" for="input_30">
          Type of Plan
          <span class="form-required">
            *
          </span>
        </label>
        <div id="cid_30" class="form-input jf-required">
          <select class="form-dropdown validate[required]" id="input_30" name="q30_typeOf30" style="width:150px" data-component="dropdown" required="" aria-labelledby="label_30">
            <option value="">  </option>
            <?php echo $planinput30; ?>
          </select>
        </div>
      </li>
      <li class="form-line jf-required" data-type="control_radio" id="id_106">
        <label class="form-label form-label-left form-label-auto" id="label_106" for="input_106">
          Group of Plan
          <span class="form-required">
            *
          </span>
        </label>
        <div id="cid_106" class="form-input jf-required">
          <div class="form-single-column" role="group" aria-labelledby="label_106" data-component="radio">
            <span class="form-radio-item" style="clear:left">
              <span class="dragger-item">
              </span>
              <input type="radio" class="form-radio validate[required]" id="input_106_0" name="q106_groupOf" value="<?=$xdogroupoplan;?>" required="" />
              <label id="label_input_106_0" for="input_106_0"> <?=$xdogroupoplan;?> </label>
              <input type="radio" class="form-radio validate[required]" id="input_106_1" name="q106_groupOf" value="<?=$xdogroupoplan2;?>" required="" />
              <label id="label_input_106_1" for="input_106_1"> <?=$xdogroupoplan2;?> </label>

            </span>
            <span class="form-radio-item" style="clear:left">
              <span class="dragger-item">
              </span>
             
            </span>
          </div>
        </div>
      </li>
      <li class="form-line jf-required" data-type="control_address" id="id_20">
        <label class="form-label form-label-left form-label-auto" id="label_20" for="input_20undefined">
          Address
          <span class="form-required">
            *
          </span>
        </label>
        <div id="cid_20" class="form-input jf-required">
          <div summary="" class="form-address-table jsTest-addressField">
            <div class="form-address-line-wrapper jsTest-address-line-wrapperField">
              <span class="form-address-line form-address-street-line jsTest-address-lineField">
                <span class="form-sub-label-container" style="vertical-align:top">
                  <input type="text" id="input_20_addr_line1" name="q20_address[addr_line1]" class="form-textbox validate[required] form-address-line" value="" data-component="address_line_1" aria-labelledby="label_20 sublabel_20_addr_line1" required="" />
                  <label class="form-sub-label" for="input_20_addr_line1" id="sublabel_20_addr_line1" style="min-height:13px" aria-hidden="false"> Street Address </label>
                </span>
              </span>
            </div>
            <div class="form-address-line-wrapper jsTest-address-line-wrapperField">
              <span class="form-address-line form-address-city-line jsTest-address-lineField ">
                <span class="form-sub-label-container" style="vertical-align:top">
                  <input type="text" id="input_20_city" name="q20_address[city]" class="form-textbox validate[required] form-address-city" value="" data-component="city" aria-labelledby="label_20 sublabel_20_city" required="" />
                  <label class="form-sub-label" for="input_20_city" id="sublabel_20_city" style="min-height:13px" aria-hidden="false"> City </label>
                </span>
              </span>
              <span class="form-address-line form-address-state-line jsTest-address-lineField ">
                <span class="form-sub-label-container" style="vertical-align:top">
                  <input type="text" id="input_20_state" name="q20_address[state]" class="form-textbox validate[required] form-address-state" value="" data-component="state" aria-labelledby="label_20 sublabel_20_state" required="" />
                  <label class="form-sub-label" for="input_20_state" id="sublabel_20_state" style="min-height:13px" aria-hidden="false"> State </label>
                </span>
              </span>
            </div>
            <div class="form-address-line-wrapper jsTest-address-line-wrapperField">
              <span class="form-address-line form-address-zip-line jsTest-address-lineField ">
                <span class="form-sub-label-container" style="vertical-align:top">
                  <input type="text" id="input_20_postal" name="q20_address[postal]" class="form-textbox form-address-postal" value="" data-component="zip" aria-labelledby="label_20 sublabel_20_postal" />
                  <label class="form-sub-label" for="input_20_postal" id="sublabel_20_postal" style="min-height:13px" aria-hidden="false"> Post Code </label>
                </span>
              </span>
              <span class="form-address-line form-address-country-line jsTest-address-lineField ">
                <span class="form-sub-label-container" style="vertical-align:top">
                  <select class="form-dropdown validate[required] form-address-country noTranslate" name="q20_address[country]" id="input_20_country" data-component="country" required="" aria-labelledby="label_20 sublabel_20_country">
                    <option value=""> Please Select </option>
                    <option value="United States"> United States </option>
                    <option value="Afghanistan"> Afghanistan </option>
                    <option value="Albania"> Albania </option>
                    <option value="Algeria"> Algeria </option>
                    <option value="American Samoa"> American Samoa </option>
                    <option value="Andorra"> Andorra </option>
                    <option value="Angola"> Angola </option>
                    <option value="Anguilla"> Anguilla </option>
                    <option value="Antigua and Barbuda"> Antigua and Barbuda </option>
                    <option value="Argentina"> Argentina </option>
                    <option value="Armenia"> Armenia </option>
                    <option value="Aruba"> Aruba </option>
                    <option value="Australia"> Australia </option>
                    <option value="Austria"> Austria </option>
                    <option value="Azerbaijan"> Azerbaijan </option>
                    <option value="The Bahamas"> The Bahamas </option>
                    <option value="Bahrain"> Bahrain </option>
                    <option value="Bangladesh"> Bangladesh </option>
                    <option value="Barbados"> Barbados </option>
                    <option value="Belarus"> Belarus </option>
                    <option value="Belgium"> Belgium </option>
                    <option value="Belize"> Belize </option>
                    <option value="Benin"> Benin </option>
                    <option value="Bermuda"> Bermuda </option>
                    <option value="Bhutan"> Bhutan </option>
                    <option value="Bolivia"> Bolivia </option>
                    <option value="Bosnia and Herzegovina"> Bosnia and Herzegovina </option>
                    <option value="Botswana"> Botswana </option>
                    <option value="Brazil"> Brazil </option>
                    <option value="Brunei"> Brunei </option>
                    <option value="Bulgaria"> Bulgaria </option>
                    <option value="Burkina Faso"> Burkina Faso </option>
                    <option value="Burundi"> Burundi </option>
                    <option value="Cambodia"> Cambodia </option>
                    <option value="Cameroon"> Cameroon </option>
                    <option value="Canada"> Canada </option>
                    <option value="Cape Verde"> Cape Verde </option>
                    <option value="Cayman Islands"> Cayman Islands </option>
                    <option value="Central African Republic"> Central African Republic </option>
                    <option value="Chad"> Chad </option>
                    <option value="Chile"> Chile </option>
                    <option value="China"> China </option>
                    <option value="Christmas Island"> Christmas Island </option>
                    <option value="Cocos (Keeling) Islands"> Cocos (Keeling) Islands </option>
                    <option value="Colombia"> Colombia </option>
                    <option value="Comoros"> Comoros </option>
                    <option value="Congo"> Congo </option>
                    <option value="Cook Islands"> Cook Islands </option>
                    <option value="Costa Rica"> Costa Rica </option>
                    <option value="Cote d&#x27;Ivoire"> Cote d&#x27;Ivoire </option>
                    <option value="Croatia"> Croatia </option>
                    <option value="Cuba"> Cuba </option>
                    <option value="Curacao"> Curacao </option>
                    <option value="Cyprus"> Cyprus </option>
                    <option value="Czech Republic"> Czech Republic </option>
                    <option value="Democratic Republic of the Congo"> Democratic Republic of the Congo </option>
                    <option value="Denmark"> Denmark </option>
                    <option value="Djibouti"> Djibouti </option>
                    <option value="Dominica"> Dominica </option>
                    <option value="Dominican Republic"> Dominican Republic </option>
                    <option value="Ecuador"> Ecuador </option>
                    <option value="Egypt"> Egypt </option>
                    <option value="El Salvador"> El Salvador </option>
                    <option value="Equatorial Guinea"> Equatorial Guinea </option>
                    <option value="Eritrea"> Eritrea </option>
                    <option value="Estonia"> Estonia </option>
                    <option value="Ethiopia"> Ethiopia </option>
                    <option value="Falkland Islands"> Falkland Islands </option>
                    <option value="Faroe Islands"> Faroe Islands </option>
                    <option value="Fiji"> Fiji </option>
                    <option value="Finland"> Finland </option>
                    <option value="France"> France </option>
                    <option value="French Polynesia"> French Polynesia </option>
                    <option value="Gabon"> Gabon </option>
                    <option value="The Gambia"> The Gambia </option>
                    <option value="Georgia"> Georgia </option>
                    <option value="Germany"> Germany </option>
                    <option value="Ghana"> Ghana </option>
                    <option value="Gibraltar"> Gibraltar </option>
                    <option value="Greece"> Greece </option>
                    <option value="Greenland"> Greenland </option>
                    <option value="Grenada"> Grenada </option>
                    <option value="Guadeloupe"> Guadeloupe </option>
                    <option value="Guam"> Guam </option>
                    <option value="Guatemala"> Guatemala </option>
                    <option value="Guernsey"> Guernsey </option>
                    <option value="Guinea"> Guinea </option>
                    <option value="Guinea-Bissau"> Guinea-Bissau </option>
                    <option value="Guyana"> Guyana </option>
                    <option value="Haiti"> Haiti </option>
                    <option value="Honduras"> Honduras </option>
                    <option value="Hong Kong"> Hong Kong </option>
                    <option value="Hungary"> Hungary </option>
                    <option value="Iceland"> Iceland </option>
                    <option value="India"> India </option>
                    <option value="Indonesia"> Indonesia </option>
                    <option value="Iran"> Iran </option>
                    <option value="Iraq"> Iraq </option>
                    <option value="Ireland"> Ireland </option>
                    <option value="Israel"> Israel </option>
                    <option value="Italy"> Italy </option>
                    <option value="Jamaica"> Jamaica </option>
                    <option value="Japan"> Japan </option>
                    <option value="Jersey"> Jersey </option>
                    <option value="Jordan"> Jordan </option>
                    <option value="Kazakhstan"> Kazakhstan </option>
                    <option value="Kenya"> Kenya </option>
                    <option value="Kiribati"> Kiribati </option>
                    <option value="North Korea"> North Korea </option>
                    <option value="South Korea"> South Korea </option>
                    <option value="Kosovo"> Kosovo </option>
                    <option value="Kuwait"> Kuwait </option>
                    <option value="Kyrgyzstan"> Kyrgyzstan </option>
                    <option value="Laos"> Laos </option>
                    <option value="Latvia"> Latvia </option>
                    <option value="Lebanon"> Lebanon </option>
                    <option value="Lesotho"> Lesotho </option>
                    <option value="Liberia"> Liberia </option>
                    <option value="Libya"> Libya </option>
                    <option value="Liechtenstein"> Liechtenstein </option>
                    <option value="Lithuania"> Lithuania </option>
                    <option value="Luxembourg"> Luxembourg </option>
                    <option value="Macau"> Macau </option>
                    <option value="Macedonia"> Macedonia </option>
                    <option value="Madagascar"> Madagascar </option>
                    <option value="Malawi"> Malawi </option>
                    <option value="Malaysia"> Malaysia </option>
                    <option value="Maldives"> Maldives </option>
                    <option value="Mali"> Mali </option>
                    <option value="Malta"> Malta </option>
                    <option value="Marshall Islands"> Marshall Islands </option>
                    <option value="Martinique"> Martinique </option>
                    <option value="Mauritania"> Mauritania </option>
                    <option value="Mauritius"> Mauritius </option>
                    <option value="Mayotte"> Mayotte </option>
                    <option value="Mexico"> Mexico </option>
                    <option value="Micronesia"> Micronesia </option>
                    <option value="Moldova"> Moldova </option>
                    <option value="Monaco"> Monaco </option>
                    <option value="Mongolia"> Mongolia </option>
                    <option value="Montenegro"> Montenegro </option>
                    <option value="Montserrat"> Montserrat </option>
                    <option value="Morocco"> Morocco </option>
                    <option value="Mozambique"> Mozambique </option>
                    <option value="Myanmar"> Myanmar </option>
                    <option value="Nagorno-Karabakh"> Nagorno-Karabakh </option>
                    <option value="Namibia"> Namibia </option>
                    <option value="Nauru"> Nauru </option>
                    <option value="Nepal"> Nepal </option>
                    <option value="Netherlands"> Netherlands </option>
                    <option value="Netherlands Antilles"> Netherlands Antilles </option>
                    <option value="New Caledonia"> New Caledonia </option>
                    <option value="New Zealand"> New Zealand </option>
                    <option value="Nicaragua"> Nicaragua </option>
                    <option value="Niger"> Niger </option>
                    <option value="Nigeria"> Nigeria </option>
                    <option value="Niue"> Niue </option>
                    <option value="Norfolk Island"> Norfolk Island </option>
                    <option value="Turkish Republic of Northern Cyprus"> Turkish Republic of Northern Cyprus </option>
                    <option value="Northern Mariana"> Northern Mariana </option>
                    <option value="Norway"> Norway </option>
                    <option value="Oman"> Oman </option>
                    <option value="Pakistan"> Pakistan </option>
                    <option value="Palau"> Palau </option>
                    <option value="Palestine"> Palestine </option>
                    <option value="Panama"> Panama </option>
                    <option value="Papua New Guinea"> Papua New Guinea </option>
                    <option value="Paraguay"> Paraguay </option>
                    <option value="Peru"> Peru </option>
                    <option value="Philippines"> Philippines </option>
                    <option value="Pitcairn Islands"> Pitcairn Islands </option>
                    <option value="Poland"> Poland </option>
                    <option value="Portugal"> Portugal </option>
                    <option value="Puerto Rico"> Puerto Rico </option>
                    <option value="Qatar"> Qatar </option>
                    <option value="Republic of the Congo"> Republic of the Congo </option>
                    <option value="Romania"> Romania </option>
                    <option value="Russia"> Russia </option>
                    <option value="Rwanda"> Rwanda </option>
                    <option value="Saint Barthelemy"> Saint Barthelemy </option>
                    <option value="Saint Helena"> Saint Helena </option>
                    <option value="Saint Kitts and Nevis"> Saint Kitts and Nevis </option>
                    <option value="Saint Lucia"> Saint Lucia </option>
                    <option value="Saint Martin"> Saint Martin </option>
                    <option value="Saint Pierre and Miquelon"> Saint Pierre and Miquelon </option>
                    <option value="Saint Vincent and the Grenadines"> Saint Vincent and the Grenadines </option>
                    <option value="Samoa"> Samoa </option>
                    <option value="San Marino"> San Marino </option>
                    <option value="Sao Tome and Principe"> Sao Tome and Principe </option>
                    <option value="Saudi Arabia"> Saudi Arabia </option>
                    <option value="Senegal"> Senegal </option>
                    <option value="Serbia"> Serbia </option>
                    <option value="Seychelles"> Seychelles </option>
                    <option value="Sierra Leone"> Sierra Leone </option>
                    <option value="Singapore"> Singapore </option>
                    <option value="Slovakia"> Slovakia </option>
                    <option value="Slovenia"> Slovenia </option>
                    <option value="Solomon Islands"> Solomon Islands </option>
                    <option value="Somalia"> Somalia </option>
                    <option value="Somaliland"> Somaliland </option>
                    <option value="South Africa"> South Africa </option>
                    <option value="South Ossetia"> South Ossetia </option>
                    <option value="South Sudan"> South Sudan </option>
                    <option value="Spain"> Spain </option>
                    <option value="Sri Lanka"> Sri Lanka </option>
                    <option value="Sudan"> Sudan </option>
                    <option value="Suriname"> Suriname </option>
                    <option value="Svalbard"> Svalbard </option>
                    <option value="eSwatini"> eSwatini </option>
                    <option value="Sweden"> Sweden </option>
                    <option value="Switzerland"> Switzerland </option>
                    <option value="Syria"> Syria </option>
                    <option value="Taiwan"> Taiwan </option>
                    <option value="Tajikistan"> Tajikistan </option>
                    <option value="Tanzania"> Tanzania </option>
                    <option value="Thailand"> Thailand </option>
                    <option value="Timor-Leste"> Timor-Leste </option>
                    <option value="Togo"> Togo </option>
                    <option value="Tokelau"> Tokelau </option>
                    <option value="Tonga"> Tonga </option>
                    <option value="Transnistria Pridnestrovie"> Transnistria Pridnestrovie </option>
                    <option value="Trinidad and Tobago"> Trinidad and Tobago </option>
                    <option value="Tristan da Cunha"> Tristan da Cunha </option>
                    <option value="Tunisia"> Tunisia </option>
                    <option value="Turkey"> Turkey </option>
                    <option value="Turkmenistan"> Turkmenistan </option>
                    <option value="Turks and Caicos Islands"> Turks and Caicos Islands </option>
                    <option value="Tuvalu"> Tuvalu </option>
                    <option value="Uganda"> Uganda </option>
                    <option value="Ukraine"> Ukraine </option>
                    <option value="United Arab Emirates"> United Arab Emirates </option>
                    <option value="United Kingdom"> United Kingdom </option>
                    <option value="Uruguay"> Uruguay </option>
                    <option value="Uzbekistan"> Uzbekistan </option>
                    <option value="Vanuatu"> Vanuatu </option>
                    <option value="Vatican City"> Vatican City </option>
                    <option value="Venezuela"> Venezuela </option>
                    <option value="Vietnam"> Vietnam </option>
                    <option value="British Virgin Islands"> British Virgin Islands </option>
                    <option value="Isle of Man"> Isle of Man </option>
                    <option value="US Virgin Islands"> US Virgin Islands </option>
                    <option value="Wallis and Futuna"> Wallis and Futuna </option>
                    <option value="Western Sahara"> Western Sahara </option>
                    <option value="Yemen"> Yemen </option>
                    <option value="Zambia"> Zambia </option>
                    <option value="Zimbabwe"> Zimbabwe </option>
                    <option value="other"> Other </option>
                  </select>
                  <label class="form-sub-label" for="input_20_country" id="sublabel_20_country" style="min-height:13px" aria-hidden="false"> Country </label>
                </span>
              </span>
            </div>
          </div>
        </div>
      </li>
      <li class="<?=$classreq;?>" data-type="control_textbox" id="id_29">
        <label class="form-label form-label-left form-label-auto" id="label_29" for="input_29"> Employee ID 
        <span class ="form-required">
            <?=$reqicon;?>
        </span>
        </label>
        <div id="cid_29" class="<?=$formdivrequired;?>">
          <input type="text" id="input_29" name="q29_employeeId" data-type="input-textbox" class="form-textbox" size="30" value="" placeholder=" " data-component="textbox" aria-labelledby="label_29" />
        </div>
      </li>
      
      
      </li>
      <li class="form-line" data-type="control_textbox" id="id_24">
        <label class="form-label form-label-left form-label-auto" id="label_24" for="input_24">
          E-mail Address
          
        </label>
        <div id="cid_24" class="form-input">
          <input type="text" id="input_24" name="q24_emailAddress" class="form-textbox" size="30" value="" placeholder="ex: myname@example.com" data-component="email" aria-labelledby="label_24"/>
        </div>
      </li>
      
      <li class="form-line jf-required" data-type="control_dropdown" id="id_31">
        <label class="form-label form-label-left form-label-auto" id="label_31" for="input_31">
          Hospitals
          <span class="form-required">
            *
          </span>
        </label>
        <div id="cid_31" class="form-input jf-required">
          <span class="form-sub-label-container" style="vertical-align:top">
            <input list="input_31b" class="form-dropdown validate[required]" id="input_31" name="q31_hospitals" style="width:150px" data-component="dropdown" required="" aria-labelledby="label_31 sublabel_input_31">
              <datalist id="input_31b">
  <option value="">
  <option value="">
</datalist>
            <label class="form-sub-label" for="input_31" id="sublabel_input_31" style="min-height:15px" aria-hidden="false"> <b>NB. You Must Choose your Plan Before The Hospital List Will Display</b>
                <br> You can type the <b>State</b>, <b>Location</b> or <b>Name of hospital</b> you want to choose from. choose From from the displayed hospital list* </br>
                </label>
          </span>
        </div>
      </li>
      <li class="form-line jf-required" data-type="control_fileupload" id="id_99">
        <label class="form-label form-label-left form-label-auto" id="label_99" for="input_99">
          Passport
          <span class="form-required">
            *
          </span>
        </label>
        <div id="cid_99" class="form-input jf-required">
          <span class="form-sub-label-container" style="vertical-align:top">
            <input type="file" id="input_99" name="q99_passport" class="form-upload validate[required]" data-imagevalidate="yes" data-file-accept="jpg, jpeg, png, gif" data-file-maxsize="10240" data-file-minsize="0" data-file-limit="" data-component="fileupload" required="" />
            <label class="form-sub-label" for="input_99" style="min-height:13px" aria-hidden="false"> Select passport photo from your device. </label>
          </span>
        </div>
      </li>
      <li class="form-line" data-type="control_divider" id="id_34">
        <div id="cid_34" class="form-input-wide">
          <div data-component="divider" style="border-bottom:1px solid #e6e6e6;height:1px;margin-left:0px;margin-right:0px;margin-top:5px;margin-bottom:5px">
          </div>
        </div>
      </li>
      
      
      <li class="form-line" data-type="control_text" id="id_35">
        <div id="cid_35" class="form-input-wide">
          <div id="text_35" class="form-html" data-component="text">
            <p style="text-align: center;"><span style="font-size: 18pt; color: #0000ff;"><strong><strong>SPOUSE</strong></strong></span></p>
          </div>
        </div>
      </li>
      <li class="form-line" data-type="control_textbox" id="id_36">
        <label class="form-label form-label-left form-label-auto" id="label_36" for="input_36"> Spouse's Surname </label>
        <div id="cid_36" class="form-input">
          <input<?=$xdoreadonly;?> type="text" id="input_36" name="q36_spousesSurname" data-type="input-textbox" class="form-textbox" size="30" value="" placeholder=" " data-component="textbox" aria-labelledby="label_36" />
        </div>
      </li>
      <li class="form-line" data-type="control_textbox" id="id_37">
        <label class="form-label form-label-left form-label-auto" id="label_37" for="input_37"> Spouse's First Name </label>
        <div id="cid_37" class="form-input">
          <input<?=$xdoreadonly;?> type="text" id="input_37" name="q37_spousesFirst" data-type="input-textbox" class="form-textbox" size="30" value="" placeholder=" " data-component="textbox" aria-labelledby="label_37" />
        </div>
      </li>
      <li class="form-line" data-type="control_textbox" id="id_38">
        <label class="form-label form-label-left form-label-auto" id="label_38" for="input_38"> Spouse's Middle Name </label>
        <div id="cid_38" class="form-input">
          <input<?=$xdoreadonly;?> type="text" id="input_38" name="q38_spousesMiddle" data-type="input-textbox" class="form-textbox" size="30" value="" placeholder=" " data-component="textbox" aria-labelledby="label_38" />
        </div>
      </li>
      <li class="form-line" data-type="control_phone" id="id_41">
        <label class="form-label form-label-left form-label-auto" id="label_41" for="input_41_area"> Spouse's Phone Number </label>
        <div id="cid_41" class="form-input">
          <div data-wrapper-react="true">
            <span class="form-sub-label-container" style="vertical-align:top" data-input-type="areaCode">
              <input<?=$xdoreadonly;?> type="tel" id="input_41_area" name="q41_spousesPhone[area]" class="form-textbox" value="" data-component="areaCode" aria-labelledby="label_41 sublabel_41_area" />
              <span class="phone-separate" aria-hidden="true">
                 -
              </span>
              <label class="form-sub-label" for="input_41_area" id="sublabel_41_area" style="min-height:13px" aria-hidden="false"> Area Code </label>
            </span>
            <span class="form-sub-label-container" style="vertical-align:top" data-input-type="phone">
              <input<?=$xdoreadonly;?> type="tel" id="input_41_phone" name="q41_spousesPhone[phone]" class="form-textbox" value="" data-component="phone" aria-labelledby="label_41 sublabel_41_phone" />
              <label class="form-sub-label" for="input_41_phone" id="sublabel_41_phone" style="min-height:13px" aria-hidden="false"> Phone Number </label>
            </span>
          </div>
        </div>
      </li>
      <li class="form-line" data-type="control_birthdate" id="id_42">
        <label class="form-label form-label-left form-label-auto" id="label_42" for="input_42"> Spouse's Date of Birth </label>
        <div id="cid_42" class="form-input">
          <div data-wrapper-react="true">
            <span class="form-sub-label-container" style="vertical-align:top">
              <select name="q42_spousesDate[day]" id="input_42_day" class="form-dropdown" data-component="birthdate-day" aria-labelledby="label_42 sublabel_42_day">
                <option>  </option>
                <option value="1"> 1 </option>
                <option value="2"> 2 </option>
                <option value="3"> 3 </option>
                <option value="4"> 4 </option>
                <option value="5"> 5 </option>
                <option value="6"> 6 </option>
                <option value="7"> 7 </option>
                <option value="8"> 8 </option>
                <option value="9"> 9 </option>
                <option value="10"> 10 </option>
                <option value="11"> 11 </option>
                <option value="12"> 12 </option>
                <option value="13"> 13 </option>
                <option value="14"> 14 </option>
                <option value="15"> 15 </option>
                <option value="16"> 16 </option>
                <option value="17"> 17 </option>
                <option value="18"> 18 </option>
                <option value="19"> 19 </option>
                <option value="20"> 20 </option>
                <option value="21"> 21 </option>
                <option value="22"> 22 </option>
                <option value="23"> 23 </option>
                <option value="24"> 24 </option>
                <option value="25"> 25 </option>
                <option value="26"> 26 </option>
                <option value="27"> 27 </option>
                <option value="28"> 28 </option>
                <option value="29"> 29 </option>
                <option value="30"> 30 </option>
                <option value="31"> 31 </option>
              </select>
              <label class="form-sub-label" for="input_42_day" id="sublabel_42_day" style="min-height:13px" aria-hidden="false"> Day </label>
            </span>
            <span class="form-sub-label-container" style="vertical-align:top">
              <select name="q42_spousesDate[month]" id="input_42_month" class="form-dropdown" data-component="birthdate-month" aria-labelledby="label_42 sublabel_42_month">
                <option>  </option>
                <option value="January"> January </option>
                <option value="February"> February </option>
                <option value="March"> March </option>
                <option value="April"> April </option>
                <option value="May"> May </option>
                <option value="June"> June </option>
                <option value="July"> July </option>
                <option value="August"> August </option>
                <option value="September"> September </option>
                <option value="October"> October </option>
                <option value="November"> November </option>
                <option value="December"> December </option>
              </select>
              <label class="form-sub-label" for="input_42_month" id="sublabel_42_month" style="min-height:13px" aria-hidden="false"> Month </label>
            </span>
            <span class="form-sub-label-container" style="vertical-align:top">
              <select name="q42_spousesDate[year]" id="input_42_year" class="form-dropdown" data-component="birthdate-year" aria-labelledby="label_42 sublabel_42_year">
                <option>  </option>
                <option value="2022"> 2022 </option>
                <option value="2021"> 2021 </option>
                <option value="2020"> 2020 </option>
                <option value="2019"> 2019 </option>
                <option value="2018"> 2018 </option>
                <option value="2017"> 2017 </option>
                <option value="2016"> 2016 </option>
                <option value="2015"> 2015 </option>
                <option value="2014"> 2014 </option>
                <option value="2013"> 2013 </option>
                <option value="2012"> 2012 </option>
                <option value="2011"> 2011 </option>
                <option value="2010"> 2010 </option>
                <option value="2009"> 2009 </option>
                <option value="2008"> 2008 </option>
                <option value="2007"> 2007 </option>
                <option value="2006"> 2006 </option>
                <option value="2005"> 2005 </option>
                <option value="2004"> 2004 </option>
                <option value="2003"> 2003 </option>
                <option value="2002"> 2002 </option>
                <option value="2001"> 2001 </option>
                <option value="2000"> 2000 </option>
                <option value="1999"> 1999 </option>
                <option value="1998"> 1998 </option>
                <option value="1997"> 1997 </option>
                <option value="1996"> 1996 </option>
                <option value="1995"> 1995 </option>
                <option value="1994"> 1994 </option>
                <option value="1993"> 1993 </option>
                <option value="1992"> 1992 </option>
                <option value="1991"> 1991 </option>
                <option value="1990"> 1990 </option>
                <option value="1989"> 1989 </option>
                <option value="1988"> 1988 </option>
                <option value="1987"> 1987 </option>
                <option value="1986"> 1986 </option>
                <option value="1985"> 1985 </option>
                <option value="1984"> 1984 </option>
                <option value="1983"> 1983 </option>
                <option value="1982"> 1982 </option>
                <option value="1981"> 1981 </option>
                <option value="1980"> 1980 </option>
                <option value="1979"> 1979 </option>
                <option value="1978"> 1978 </option>
                <option value="1977"> 1977 </option>
                <option value="1976"> 1976 </option>
                <option value="1975"> 1975 </option>
                <option value="1974"> 1974 </option>
                <option value="1973"> 1973 </option>
                <option value="1972"> 1972 </option>
                <option value="1971"> 1971 </option>
                <option value="1970"> 1970 </option>
                <option value="1969"> 1969 </option>
                <option value="1968"> 1968 </option>
                <option value="1967"> 1967 </option>
                <option value="1966"> 1966 </option>
                <option value="1965"> 1965 </option>
                <option value="1964"> 1964 </option>
                <option value="1963"> 1963 </option>
                <option value="1962"> 1962 </option>
                <option value="1961"> 1961 </option>
                <option value="1960"> 1960 </option>
                <option value="1959"> 1959 </option>
                <option value="1958"> 1958 </option>
                <option value="1957"> 1957 </option>
                <option value="1956"> 1956 </option>
                <option value="1955"> 1955 </option>
                <option value="1954"> 1954 </option>
                <option value="1953"> 1953 </option>
                <option value="1952"> 1952 </option>
                <option value="1951"> 1951 </option>
                <option value="1950"> 1950 </option>
                <option value="1949"> 1949 </option>
                <option value="1948"> 1948 </option>
                <option value="1947"> 1947 </option>
                <option value="1946"> 1946 </option>
                <option value="1945"> 1945 </option>
                <option value="1944"> 1944 </option>
                <option value="1943"> 1943 </option>
                <option value="1942"> 1942 </option>
                <option value="1941"> 1941 </option>
                <option value="1940"> 1940 </option>
                <option value="1939"> 1939 </option>
                <option value="1938"> 1938 </option>
                <option value="1937"> 1937 </option>
                <option value="1936"> 1936 </option>
                <option value="1935"> 1935 </option>
                <option value="1934"> 1934 </option>
                <option value="1933"> 1933 </option>
                <option value="1932"> 1932 </option>
                <option value="1931"> 1931 </option>
                <option value="1930"> 1930 </option>
                <option value="1929"> 1929 </option>
                <option value="1928"> 1928 </option>
                <option value="1927"> 1927 </option>
                <option value="1926"> 1926 </option>
                <option value="1925"> 1925 </option>
                <option value="1924"> 1924 </option>
                <option value="1923"> 1923 </option>
                <option value="1922"> 1922 </option>
                <option value="1921"> 1921 </option>
                <option value="1920"> 1920 </option>
              </select>
              <label class="form-sub-label" for="input_42_year" id="sublabel_42_year" style="min-height:13px" aria-hidden="false"> Year </label>
            </span>
          </div>
        </div>
      </li>
      <li class="form-line" data-type="control_dropdown" id="id_87">
        <label class="form-label form-label-left form-label-auto" id="label_87" for="input_87"> Spouse's Gender </label>
        <div id="cid_87" class="form-input">
          <select class="form-dropdown" id="input_87" name="q87_spousesGender" style="width:150px" data-component="dropdown" aria-labelledby="label_87">
            <option value="">  </option>
            <option value="Male"> Male </option>
            <option value="Female"> Female </option>
            <option value="Not willing to Disclose"> Not willing to Disclose </option>
          </select>
        </div>
      </li>
      <li class="form-line" data-type="control_dropdown" id="id_58">
        <label class="form-label form-label-left form-label-auto" id="label_58" for="input_58"> Spouse's Hospitals </label>
        <div id="cid_58" class="form-input">
          <span class="form-sub-label-container" style="vertical-align:top">
            <input<?=$xdoreadonly;?> list="input_58b" class="form-dropdown" id="input_58" name="q58_spousesHospitals" style="width:150px" data-component="dropdown" aria-labelledby="label_58 sublabel_input_58">
              <datalist id="input_58b">
  <option value="">
  <option value="">
</datalist>
            <label class="form-sub-label" for="input_58" id="sublabel_input_58" style="min-height:13px" aria-hidden="false"><b>NB. You Must Choose your Plan Before The Hospital List Will Display</b>
                <br> You can type the <b>State</b>, <b>Location</b> or <b>Name of hospital</b> you want to choose from. choose From from the displayed hospital list* </br>
                </label>
          </span>
        </div>
      </li>
      <li class="form-line" data-type="control_fileupload" id="id_100">
        <label class="form-label form-label-left form-label-auto" id="label_100" for="input_100"> Spouse's Passport </label>
        <div id="cid_100" class="form-input">
          <span class="form-sub-label-container" style="vertical-align:top">
            <input<?=$xdoreadonly;?> type="file" id="input_100" name="q100_spousesPassport" class="form-upload" data-imagevalidate="yes" data-file-accept="jpg, jpeg, png, gif" data-file-maxsize="10240" data-file-minsize="0" data-file-limit="" data-component="fileupload" />
            <label class="form-sub-label" for="input_100" style="min-height:13px" aria-hidden="false"> Select passport photo from your device. </label>
          </span>
        </div>
      </li>
      <li class="form-line" data-type="control_divider" id="id_45">
        <div id="cid_45" class="form-input-wide">
          <div data-component="divider" style="border-bottom:1px solid #e6e6e6;height:1px;margin-left:0px;margin-right:0px;margin-top:5px;margin-bottom:5px">
          </div>
        </div>
      </li>
      <li class="form-line" data-type="control_text" id="id_46">
        <div id="cid_46" class="form-input-wide">
          <div id="text_46" class="form-html" data-component="text">
            <p style="text-align: center;"><span style="font-size: 18pt; color: #0000ff;"><strong><strong>DEPENDENTS<br /></strong></strong></span></p>
          </div>
        </div>
      </li>
      <li class="form-line" data-type="control_text" id="id_49">
        <div id="cid_49" class="form-input-wide">
          <div id="text_49" class="form-html" data-component="text">
            <p style="text-align: left;"><span style="font-size: 12pt; color: #ff0000;"><strong><strong>DEPENDENT 1<br /></strong></strong></span></p>
          </div>
        </div>
      </li>
      <li class="form-line" data-type="control_textbox" id="id_50">
        <label class="form-label form-label-left form-label-auto" id="label_50" for="input_50"> 1st Dependent's Surname </label>
        <div id="cid_50" class="form-input">
          <input<?=$xdoreadonly;?> type="text" id="input_50" name="q50_1stDependents" data-type="input-textbox" class="form-textbox" size="30" value="" placeholder=" " data-component="textbox" aria-labelledby="label_50" />
        </div>
      </li>
      <li class="form-line" data-type="control_textbox" id="id_51">
        <label class="form-label form-label-left form-label-auto" id="label_51" for="input_51"> 1st DependEnt's First Name </label>
        <div id="cid_51" class="form-input">
          <input<?=$xdoreadonly;?> type="text" id="input_51" name="q51_1stDependents51" data-type="input-textbox" class="form-textbox" size="30" value="" placeholder=" " data-component="textbox" aria-labelledby="label_51" />
        </div>
      </li>
      <li class="form-line" data-type="control_textbox" id="id_52">
        <label class="form-label form-label-left form-label-auto" id="label_52" for="input_52"> 1st Dependent's Middle Name </label>
        <div id="cid_52" class="form-input">
          <input<?=$xdoreadonly;?> type="text" id="input_52" name="q52_1stDependents52" data-type="input-textbox" class="form-textbox" size="30" value="" placeholder=" " data-component="textbox" aria-labelledby="label_52" />
        </div>
      </li>
      <li class="form-line" data-type="control_phone" id="id_54">
        <label class="form-label form-label-left form-label-auto" id="label_54" for="input_54_area"> 1st Dependent's Phone Number </label>
        <div id="cid_54" class="form-input">
          <div data-wrapper-react="true">
            <span class="form-sub-label-container" style="vertical-align:top" data-input-type="areaCode">
              <input<?=$xdoreadonly;?> type="tel" id="input_54_area" name="q54_1stDependents54[area]" class="form-textbox" value="" data-component="areaCode" aria-labelledby="label_54 sublabel_54_area" />
              <span class="phone-separate" aria-hidden="true">
                 -
              </span>
              <label class="form-sub-label" for="input_54_area" id="sublabel_54_area" style="min-height:13px" aria-hidden="false"> Area Code </label>
            </span>
            <span class="form-sub-label-container" style="vertical-align:top" data-input-type="phone">
              <input<?=$xdoreadonly;?> type="tel" id="input_54_phone" name="q54_1stDependents54[phone]" class="form-textbox" value="" data-component="phone" aria-labelledby="label_54 sublabel_54_phone" />
              <label class="form-sub-label" for="input_54_phone" id="sublabel_54_phone" style="min-height:13px" aria-hidden="false"> Phone Number </label>
            </span>
          </div>
        </div>
      </li>
      <li class="form-line" data-type="control_birthdate" id="id_55">
        <label class="form-label form-label-left form-label-auto" id="label_55" for="input_55"> 1st Dependent's Date of Birth </label>
        <div id="cid_55" class="form-input">
          <div data-wrapper-react="true">
            <span class="form-sub-label-container" style="vertical-align:top">
              <select name="q55_1stDependents55[day]" id="input_55_day" class="form-dropdown" data-component="birthdate-day" aria-labelledby="label_55 sublabel_55_day">
                <option>  </option>
                <option value="1"> 1 </option>
                <option value="2"> 2 </option>
                <option value="3"> 3 </option>
                <option value="4"> 4 </option>
                <option value="5"> 5 </option>
                <option value="6"> 6 </option>
                <option value="7"> 7 </option>
                <option value="8"> 8 </option>
                <option value="9"> 9 </option>
                <option value="10"> 10 </option>
                <option value="11"> 11 </option>
                <option value="12"> 12 </option>
                <option value="13"> 13 </option>
                <option value="14"> 14 </option>
                <option value="15"> 15 </option>
                <option value="16"> 16 </option>
                <option value="17"> 17 </option>
                <option value="18"> 18 </option>
                <option value="19"> 19 </option>
                <option value="20"> 20 </option>
                <option value="21"> 21 </option>
                <option value="22"> 22 </option>
                <option value="23"> 23 </option>
                <option value="24"> 24 </option>
                <option value="25"> 25 </option>
                <option value="26"> 26 </option>
                <option value="27"> 27 </option>
                <option value="28"> 28 </option>
                <option value="29"> 29 </option>
                <option value="30"> 30 </option>
                <option value="31"> 31 </option>
              </select>
              <label class="form-sub-label" for="input_55_day" id="sublabel_55_day" style="min-height:13px" aria-hidden="false"> Day </label>
            </span>
            <span class="form-sub-label-container" style="vertical-align:top">
              <select name="q55_1stDependents55[month]" id="input_55_month" class="form-dropdown" data-component="birthdate-month" aria-labelledby="label_55 sublabel_55_month">
                <option>  </option>
                <option value="January"> January </option>
                <option value="February"> February </option>
                <option value="March"> March </option>
                <option value="April"> April </option>
                <option value="May"> May </option>
                <option value="June"> June </option>
                <option value="July"> July </option>
                <option value="August"> August </option>
                <option value="September"> September </option>
                <option value="October"> October </option>
                <option value="November"> November </option>
                <option value="December"> December </option>
              </select>
              <label class="form-sub-label" for="input_55_month" id="sublabel_55_month" style="min-height:13px" aria-hidden="false"> Month </label>
            </span>
            <span class="form-sub-label-container" style="vertical-align:top">
              <select name="q55_1stDependents55[year]" id="input_55_year" class="form-dropdown" data-component="birthdate-year" aria-labelledby="label_55 sublabel_55_year">
                <option>  </option>
                <option value="2022"> 2022 </option>
                <option value="2021"> 2021 </option>
                <option value="2020"> 2020 </option>
                <option value="2019"> 2019 </option>
                <option value="2018"> 2018 </option>
                <option value="2017"> 2017 </option>
                <option value="2016"> 2016 </option>
                <option value="2015"> 2015 </option>
                <option value="2014"> 2014 </option>
                <option value="2013"> 2013 </option>
                <option value="2012"> 2012 </option>
                <option value="2011"> 2011 </option>
                <option value="2010"> 2010 </option>
                <option value="2009"> 2009 </option>
                <option value="2008"> 2008 </option>
                <option value="2007"> 2007 </option>
                <option value="2006"> 2006 </option>
                <option value="2005"> 2005 </option>
                <option value="2004"> 2004 </option>
                <option value="2003"> 2003 </option>
                <option value="2002"> 2002 </option>
                <option value="2001"> 2001 </option>
                <option value="2000"> 2000 </option>
                <option value="1999"> 1999 </option>
                <option value="1998"> 1998 </option>
                <option value="1997"> 1997 </option>
                <option value="1996"> 1996 </option>
                <option value="1995"> 1995 </option>
                <option value="1994"> 1994 </option>
                <option value="1993"> 1993 </option>
                <option value="1992"> 1992 </option>
                <option value="1991"> 1991 </option>
                <option value="1990"> 1990 </option>
                <option value="1989"> 1989 </option>
                <option value="1988"> 1988 </option>
                <option value="1987"> 1987 </option>
                <option value="1986"> 1986 </option>
                <option value="1985"> 1985 </option>
                <option value="1984"> 1984 </option>
                <option value="1983"> 1983 </option>
                <option value="1982"> 1982 </option>
                <option value="1981"> 1981 </option>
                <option value="1980"> 1980 </option>
                <option value="1979"> 1979 </option>
                <option value="1978"> 1978 </option>
                <option value="1977"> 1977 </option>
                <option value="1976"> 1976 </option>
                <option value="1975"> 1975 </option>
                <option value="1974"> 1974 </option>
                <option value="1973"> 1973 </option>
                <option value="1972"> 1972 </option>
                <option value="1971"> 1971 </option>
                <option value="1970"> 1970 </option>
                <option value="1969"> 1969 </option>
                <option value="1968"> 1968 </option>
                <option value="1967"> 1967 </option>
                <option value="1966"> 1966 </option>
                <option value="1965"> 1965 </option>
                <option value="1964"> 1964 </option>
                <option value="1963"> 1963 </option>
                <option value="1962"> 1962 </option>
                <option value="1961"> 1961 </option>
                <option value="1960"> 1960 </option>
                <option value="1959"> 1959 </option>
                <option value="1958"> 1958 </option>
                <option value="1957"> 1957 </option>
                <option value="1956"> 1956 </option>
                <option value="1955"> 1955 </option>
                <option value="1954"> 1954 </option>
                <option value="1953"> 1953 </option>
                <option value="1952"> 1952 </option>
                <option value="1951"> 1951 </option>
                <option value="1950"> 1950 </option>
                <option value="1949"> 1949 </option>
                <option value="1948"> 1948 </option>
                <option value="1947"> 1947 </option>
                <option value="1946"> 1946 </option>
                <option value="1945"> 1945 </option>
                <option value="1944"> 1944 </option>
                <option value="1943"> 1943 </option>
                <option value="1942"> 1942 </option>
                <option value="1941"> 1941 </option>
                <option value="1940"> 1940 </option>
                <option value="1939"> 1939 </option>
                <option value="1938"> 1938 </option>
                <option value="1937"> 1937 </option>
                <option value="1936"> 1936 </option>
                <option value="1935"> 1935 </option>
                <option value="1934"> 1934 </option>
                <option value="1933"> 1933 </option>
                <option value="1932"> 1932 </option>
                <option value="1931"> 1931 </option>
                <option value="1930"> 1930 </option>
                <option value="1929"> 1929 </option>
                <option value="1928"> 1928 </option>
                <option value="1927"> 1927 </option>
                <option value="1926"> 1926 </option>
                <option value="1925"> 1925 </option>
                <option value="1924"> 1924 </option>
                <option value="1923"> 1923 </option>
                <option value="1922"> 1922 </option>
                <option value="1921"> 1921 </option>
                <option value="1920"> 1920 </option>
              </select>
              <label class="form-sub-label" for="input_55_year" id="sublabel_55_year" style="min-height:13px" aria-hidden="false"> Year </label>
            </span>
          </div>
        </div>
      </li>
      <li class="form-line" data-type="control_dropdown" id="id_89">
        <label class="form-label form-label-left form-label-auto" id="label_89" for="input_89"> 1st Dependent's Gender </label>
        <div id="cid_89" class="form-input">
          <select class="form-dropdown" id="input_89" name="q89_1stDependents89" style="width:150px" data-component="dropdown" aria-labelledby="label_89">
            <option value="">  </option>
            <option value="Male"> Male </option>
            <option value="Female"> Female </option>
            <option value="Not willing to Disclose"> Not willing to Disclose </option>
          </select>
        </div>
      </li>
      <li class="form-line" data-type="control_dropdown" id="id_90">
        <label class="form-label form-label-left form-label-auto" id="label_90" for="input_90"> 1st Dependent's Hospitals </label>
        <div id="cid_90" class="form-input">
          <span class="form-sub-label-container" style="vertical-align:top">
            <input<?=$xdoreadonly;?> list="input_90b" class="form-dropdown" id="input_90" name="q90_1stDependents90" style="width:150px" data-component="dropdown" aria-labelledby="label_90 sublabel_input_90">
              <datalist id="input_90b">
  <option value="">
  <option value="">
</datalist>
            <label class="form-sub-label" for="input_90" id="sublabel_input_90" style="min-height:13px" aria-hidden="false"><b>NB. You Must Choose your Plan Before The Hospital List Will Display</b>
                <br> You can type the <b>State</b>, <b>Location</b> or <b>Name of hospital</b> you want to choose from. choose From from the displayed hospital list* </br>
                </label>
          </span>
        </div>
      </li>
      <li class="form-line" data-type="control_fileupload" id="id_101">
        <label class="form-label form-label-left form-label-auto" id="label_101" for="input_101"> 1st Dependent's Passport </label>
        <div id="cid_101" class="form-input">
          <span class="form-sub-label-container" style="vertical-align:top">
            <input<?=$xdoreadonly;?> type="file" id="input_101" name="q101_1stDependents101" class="form-upload" data-imagevalidate="yes" data-file-accept="jpg, jpeg, png, gif" data-file-maxsize="10240" data-file-minsize="0" data-file-limit="" data-component="fileupload" />
            <label class="form-sub-label" for="input_101" style="min-height:13px" aria-hidden="false"> Select passport photo from your device. </label>
          </span>
        </div>
      </li>
      <li class="form-line" data-type="control_text" id="id_59">
        <div id="cid_59" class="form-input-wide">
          <div id="text_59" class="form-html" data-component="text">
            <p style="text-align: left;"><span style="font-size: 12pt; color: #ff0000;"><strong><strong>DEPENDENT 2<br /></strong></strong></span></p>
          </div>
        </div>
      </li>
      <li class="form-line" data-type="control_textbox" id="id_60">
        <label class="form-label form-label-left form-label-auto" id="label_60" for="input_60"> 2nd Dependent's Surname </label>
        <div id="cid_60" class="form-input">
          <input<?=$xdoreadonly;?> type="text" id="input_60" name="q60_2ndDependents" data-type="input-textbox" class="form-textbox" size="30" value="" placeholder=" " data-component="textbox" aria-labelledby="label_60" />
        </div>
      </li>
      <li class="form-line" data-type="control_textbox" id="id_61">
        <label class="form-label form-label-left form-label-auto" id="label_61" for="input_61"> 2nd Dependent's First Name </label>
        <div id="cid_61" class="form-input">
          <input<?=$xdoreadonly;?> type="text" id="input_61" name="q61_2ndDependents61" data-type="input-textbox" class="form-textbox" size="30" value="" placeholder=" " data-component="textbox" aria-labelledby="label_61" />
        </div>
      </li>
      <li class="form-line" data-type="control_textbox" id="id_62">
        <label class="form-label form-label-left form-label-auto" id="label_62" for="input_62"> 2nd Dependent's Middle Name </label>
        <div id="cid_62" class="form-input">
          <input<?=$xdoreadonly;?> type="text" id="input_62" name="q62_2ndDependents62" data-type="input-textbox" class="form-textbox" size="30" value="" placeholder=" " data-component="textbox" aria-labelledby="label_62" />
        </div>
      </li>
      <li class="form-line" data-type="control_phone" id="id_64">
        <label class="form-label form-label-left form-label-auto" id="label_64" for="input_64_area"> 2nd Dependent's Phone Number </label>
        <div id="cid_64" class="form-input">
          <div data-wrapper-react="true">
            <span class="form-sub-label-container" style="vertical-align:top" data-input-type="areaCode">
              <input<?=$xdoreadonly;?> type="tel" id="input_64_area" name="q64_2ndDependents64[area]" class="form-textbox" value="" data-component="areaCode" aria-labelledby="label_64 sublabel_64_area" />
              <span class="phone-separate" aria-hidden="true">
                 -
              </span>
              <label class="form-sub-label" for="input_64_area" id="sublabel_64_area" style="min-height:13px" aria-hidden="false"> Area Code </label>
            </span>
            <span class="form-sub-label-container" style="vertical-align:top" data-input-type="phone">
              <input<?=$xdoreadonly;?> type="tel" id="input_64_phone" name="q64_2ndDependents64[phone]" class="form-textbox" value="" data-component="phone" aria-labelledby="label_64 sublabel_64_phone" />
              <label class="form-sub-label" for="input_64_phone" id="sublabel_64_phone" style="min-height:13px" aria-hidden="false"> Phone Number </label>
            </span>
          </div>
        </div>
      </li>
      <li class="form-line" data-type="control_birthdate" id="id_65">
        <label class="form-label form-label-left form-label-auto" id="label_65" for="input_65"> 2nd Dependent's Date of Birth </label>
        <div id="cid_65" class="form-input">
          <div data-wrapper-react="true">
            <span class="form-sub-label-container" style="vertical-align:top">
              <select name="q65_2ndDependents65[day]" id="input_65_day" class="form-dropdown" data-component="birthdate-day" aria-labelledby="label_65 sublabel_65_day">
                <option>  </option>
                <option value="1"> 1 </option>
                <option value="2"> 2 </option>
                <option value="3"> 3 </option>
                <option value="4"> 4 </option>
                <option value="5"> 5 </option>
                <option value="6"> 6 </option>
                <option value="7"> 7 </option>
                <option value="8"> 8 </option>
                <option value="9"> 9 </option>
                <option value="10"> 10 </option>
                <option value="11"> 11 </option>
                <option value="12"> 12 </option>
                <option value="13"> 13 </option>
                <option value="14"> 14 </option>
                <option value="15"> 15 </option>
                <option value="16"> 16 </option>
                <option value="17"> 17 </option>
                <option value="18"> 18 </option>
                <option value="19"> 19 </option>
                <option value="20"> 20 </option>
                <option value="21"> 21 </option>
                <option value="22"> 22 </option>
                <option value="23"> 23 </option>
                <option value="24"> 24 </option>
                <option value="25"> 25 </option>
                <option value="26"> 26 </option>
                <option value="27"> 27 </option>
                <option value="28"> 28 </option>
                <option value="29"> 29 </option>
                <option value="30"> 30 </option>
                <option value="31"> 31 </option>
              </select>
              <label class="form-sub-label" for="input_65_day" id="sublabel_65_day" style="min-height:13px" aria-hidden="false"> Day </label>
            </span>
            <span class="form-sub-label-container" style="vertical-align:top">
              <select name="q65_2ndDependents65[month]" id="input_65_month" class="form-dropdown" data-component="birthdate-month" aria-labelledby="label_65 sublabel_65_month">
                <option>  </option>
                <option value="January"> January </option>
                <option value="February"> February </option>
                <option value="March"> March </option>
                <option value="April"> April </option>
                <option value="May"> May </option>
                <option value="June"> June </option>
                <option value="July"> July </option>
                <option value="August"> August </option>
                <option value="September"> September </option>
                <option value="October"> October </option>
                <option value="November"> November </option>
                <option value="December"> December </option>
              </select>
              <label class="form-sub-label" for="input_65_month" id="sublabel_65_month" style="min-height:13px" aria-hidden="false"> Month </label>
            </span>
            <span class="form-sub-label-container" style="vertical-align:top">
              <select name="q65_2ndDependents65[year]" id="input_65_year" class="form-dropdown" data-component="birthdate-year" aria-labelledby="label_65 sublabel_65_year">
                <option>  </option>
                <option value="2022"> 2022 </option>
                <option value="2021"> 2021 </option>
                <option value="2020"> 2020 </option>
                <option value="2019"> 2019 </option>
                <option value="2018"> 2018 </option>
                <option value="2017"> 2017 </option>
                <option value="2016"> 2016 </option>
                <option value="2015"> 2015 </option>
                <option value="2014"> 2014 </option>
                <option value="2013"> 2013 </option>
                <option value="2012"> 2012 </option>
                <option value="2011"> 2011 </option>
                <option value="2010"> 2010 </option>
                <option value="2009"> 2009 </option>
                <option value="2008"> 2008 </option>
                <option value="2007"> 2007 </option>
                <option value="2006"> 2006 </option>
                <option value="2005"> 2005 </option>
                <option value="2004"> 2004 </option>
                <option value="2003"> 2003 </option>
                <option value="2002"> 2002 </option>
                <option value="2001"> 2001 </option>
                <option value="2000"> 2000 </option>
                <option value="1999"> 1999 </option>
                <option value="1998"> 1998 </option>
                <option value="1997"> 1997 </option>
                <option value="1996"> 1996 </option>
                <option value="1995"> 1995 </option>
                <option value="1994"> 1994 </option>
                <option value="1993"> 1993 </option>
                <option value="1992"> 1992 </option>
                <option value="1991"> 1991 </option>
                <option value="1990"> 1990 </option>
                <option value="1989"> 1989 </option>
                <option value="1988"> 1988 </option>
                <option value="1987"> 1987 </option>
                <option value="1986"> 1986 </option>
                <option value="1985"> 1985 </option>
                <option value="1984"> 1984 </option>
                <option value="1983"> 1983 </option>
                <option value="1982"> 1982 </option>
                <option value="1981"> 1981 </option>
                <option value="1980"> 1980 </option>
                <option value="1979"> 1979 </option>
                <option value="1978"> 1978 </option>
                <option value="1977"> 1977 </option>
                <option value="1976"> 1976 </option>
                <option value="1975"> 1975 </option>
                <option value="1974"> 1974 </option>
                <option value="1973"> 1973 </option>
                <option value="1972"> 1972 </option>
                <option value="1971"> 1971 </option>
                <option value="1970"> 1970 </option>
                <option value="1969"> 1969 </option>
                <option value="1968"> 1968 </option>
                <option value="1967"> 1967 </option>
                <option value="1966"> 1966 </option>
                <option value="1965"> 1965 </option>
                <option value="1964"> 1964 </option>
                <option value="1963"> 1963 </option>
                <option value="1962"> 1962 </option>
                <option value="1961"> 1961 </option>
                <option value="1960"> 1960 </option>
                <option value="1959"> 1959 </option>
                <option value="1958"> 1958 </option>
                <option value="1957"> 1957 </option>
                <option value="1956"> 1956 </option>
                <option value="1955"> 1955 </option>
                <option value="1954"> 1954 </option>
                <option value="1953"> 1953 </option>
                <option value="1952"> 1952 </option>
                <option value="1951"> 1951 </option>
                <option value="1950"> 1950 </option>
                <option value="1949"> 1949 </option>
                <option value="1948"> 1948 </option>
                <option value="1947"> 1947 </option>
                <option value="1946"> 1946 </option>
                <option value="1945"> 1945 </option>
                <option value="1944"> 1944 </option>
                <option value="1943"> 1943 </option>
                <option value="1942"> 1942 </option>
                <option value="1941"> 1941 </option>
                <option value="1940"> 1940 </option>
                <option value="1939"> 1939 </option>
                <option value="1938"> 1938 </option>
                <option value="1937"> 1937 </option>
                <option value="1936"> 1936 </option>
                <option value="1935"> 1935 </option>
                <option value="1934"> 1934 </option>
                <option value="1933"> 1933 </option>
                <option value="1932"> 1932 </option>
                <option value="1931"> 1931 </option>
                <option value="1930"> 1930 </option>
                <option value="1929"> 1929 </option>
                <option value="1928"> 1928 </option>
                <option value="1927"> 1927 </option>
                <option value="1926"> 1926 </option>
                <option value="1925"> 1925 </option>
                <option value="1924"> 1924 </option>
                <option value="1923"> 1923 </option>
                <option value="1922"> 1922 </option>
                <option value="1921"> 1921 </option>
                <option value="1920"> 1920 </option>
              </select>
              <label class="form-sub-label" for="input_65_year" id="sublabel_65_year" style="min-height:13px" aria-hidden="false"> Year </label>
            </span>
          </div>
        </div>
      </li>
      <li class="form-line" data-type="control_dropdown" id="id_91">
        <label class="form-label form-label-left form-label-auto" id="label_91" for="input_91"> 2nd Dependent's Gender </label>
        <div id="cid_91" class="form-input">
          <select class="form-dropdown" id="input_91" name="q91_2ndDependents91" style="width:150px" data-component="dropdown" aria-labelledby="label_91">
            <option value="">  </option>
            <option value="Male"> Male </option>
            <option value="Female"> Female </option>
            <option value="Not willing to Disclose"> Not willing to Disclose </option>
          </select>
        </div>
      </li>
      <li class="form-line" data-type="control_dropdown" id="id_92">
        <label class="form-label form-label-left form-label-auto" id="label_92" for="input_92"> 2nd Dependent's Hospitals </label>
        <div id="cid_92" class="form-input">
          <span class="form-sub-label-container" style="vertical-align:top">
            <input<?=$xdoreadonly;?> list="input_92b" class="form-dropdown" id="input_92" name="q92_2ndDependents92" style="width:150px" data-component="dropdown" aria-labelledby="label_92 sublabel_input_92">
              <datalist id="input_92b">
  <option value="">
  <option value="">
</datalist>
            <label class="form-sub-label" for="input_92" id="sublabel_input_92" style="min-height:13px" aria-hidden="false"><b>NB. You Must Choose your Plan Before The Hospital List Will Display</b>
                <br> You can type the <b>State</b>, <b>Location</b> or <b>Name of hospital</b> you want to choose from. choose From from the displayed hospital list* </br>
                </label>
          </span>
        </div>
      </li>
      <li class="form-line" data-type="control_fileupload" id="id_102">
        <label class="form-label form-label-left form-label-auto" id="label_102" for="input_102"> 2nd Dependent's Passport </label>
        <div id="cid_102" class="form-input">
          <span class="form-sub-label-container" style="vertical-align:top">
            <input<?=$xdoreadonly;?> type="file" id="input_102" name="q102_2ndDependents102" class="form-upload" data-imagevalidate="yes" data-file-accept="jpg, jpeg, png, gif" data-file-maxsize="10240" data-file-minsize="0" data-file-limit="" data-component="fileupload" />
            <label class="form-sub-label" for="input_102" style="min-height:13px" aria-hidden="false"> Select passport photo from your device. </label>
          </span>
        </div>
      </li>
      <li class="form-line" data-type="control_text" id="id_68">
        <div id="cid_68" class="form-input-wide">
          <div id="text_68" class="form-html" data-component="text">
            <p style="text-align: left;"><span style="font-size: 12pt; color: #ff0000;"><strong><strong>DEPENDENT 3<br /></strong></strong></span></p>
          </div>
        </div>
      </li>
      <li class="form-line" data-type="control_textbox" id="id_69">
        <label class="form-label form-label-left form-label-auto" id="label_69" for="input_69"> 3rd Dependent's Surname </label>
        <div id="cid_69" class="form-input">
          <input<?=$xdoreadonly;?> type="text" id="input_69" name="q69_3rdDependents" data-type="input-textbox" class="form-textbox" size="30" value="" placeholder=" " data-component="textbox" aria-labelledby="label_69" />
        </div>
      </li>
      <li class="form-line" data-type="control_textbox" id="id_70">
        <label class="form-label form-label-left form-label-auto" id="label_70" for="input_70"> 3rd Dependent's First Name </label>
        <div id="cid_70" class="form-input">
          <input<?=$xdoreadonly;?> type="text" id="input_70" name="q70_3rdDependents70" data-type="input-textbox" class="form-textbox" size="30" value="" placeholder=" " data-component="textbox" aria-labelledby="label_70" />
        </div>
      </li>
      <li class="form-line" data-type="control_textbox" id="id_71">
        <label class="form-label form-label-left form-label-auto" id="label_71" for="input_71"> 3rd Dependent's Middle Name </label>
        <div id="cid_71" class="form-input">
          <input<?=$xdoreadonly;?> type="text" id="input_71" name="q71_3rdDependents71" data-type="input-textbox" class="form-textbox" size="30" value="" placeholder=" " data-component="textbox" aria-labelledby="label_71" />
        </div>
      </li>
      <li class="form-line" data-type="control_phone" id="id_73">
        <label class="form-label form-label-left form-label-auto" id="label_73" for="input_73_area"> 3rd Dependent's Phone Number </label>
        <div id="cid_73" class="form-input">
          <div data-wrapper-react="true">
            <span class="form-sub-label-container" style="vertical-align:top" data-input-type="areaCode">
              <input<?=$xdoreadonly;?> type="tel" id="input_73_area" name="q73_3rdDependents73[area]" class="form-textbox" value="" data-component="areaCode" aria-labelledby="label_73 sublabel_73_area" />
              <span class="phone-separate" aria-hidden="true">
                 -
              </span>
              <label class="form-sub-label" for="input_73_area" id="sublabel_73_area" style="min-height:13px" aria-hidden="false"> Area Code </label>
            </span>
            <span class="form-sub-label-container" style="vertical-align:top" data-input-type="phone">
              <input<?=$xdoreadonly;?> type="tel" id="input_73_phone" name="q73_3rdDependents73[phone]" class="form-textbox" value="" data-component="phone" aria-labelledby="label_73 sublabel_73_phone" />
              <label class="form-sub-label" for="input_73_phone" id="sublabel_73_phone" style="min-height:13px" aria-hidden="false"> Phone Number </label>
            </span>
          </div>
        </div>
      </li>
      <li class="form-line" data-type="control_birthdate" id="id_74">
        <label class="form-label form-label-left form-label-auto" id="label_74" for="input_74"> 3rd Dependent's Date of Birth </label>
        <div id="cid_74" class="form-input">
          <div data-wrapper-react="true">
            <span class="form-sub-label-container" style="vertical-align:top">
              <select name="q74_3rdDependents74[day]" id="input_74_day" class="form-dropdown" data-component="birthdate-day" aria-labelledby="label_74 sublabel_74_day">
                <option>  </option>
                <option value="1"> 1 </option>
                <option value="2"> 2 </option>
                <option value="3"> 3 </option>
                <option value="4"> 4 </option>
                <option value="5"> 5 </option>
                <option value="6"> 6 </option>
                <option value="7"> 7 </option>
                <option value="8"> 8 </option>
                <option value="9"> 9 </option>
                <option value="10"> 10 </option>
                <option value="11"> 11 </option>
                <option value="12"> 12 </option>
                <option value="13"> 13 </option>
                <option value="14"> 14 </option>
                <option value="15"> 15 </option>
                <option value="16"> 16 </option>
                <option value="17"> 17 </option>
                <option value="18"> 18 </option>
                <option value="19"> 19 </option>
                <option value="20"> 20 </option>
                <option value="21"> 21 </option>
                <option value="22"> 22 </option>
                <option value="23"> 23 </option>
                <option value="24"> 24 </option>
                <option value="25"> 25 </option>
                <option value="26"> 26 </option>
                <option value="27"> 27 </option>
                <option value="28"> 28 </option>
                <option value="29"> 29 </option>
                <option value="30"> 30 </option>
                <option value="31"> 31 </option>
              </select>
              <label class="form-sub-label" for="input_74_day" id="sublabel_74_day" style="min-height:13px" aria-hidden="false"> Day </label>
            </span>
            <span class="form-sub-label-container" style="vertical-align:top">
              <select name="q74_3rdDependents74[month]" id="input_74_month" class="form-dropdown" data-component="birthdate-month" aria-labelledby="label_74 sublabel_74_month">
                <option>  </option>
                <option value="January"> January </option>
                <option value="February"> February </option>
                <option value="March"> March </option>
                <option value="April"> April </option>
                <option value="May"> May </option>
                <option value="June"> June </option>
                <option value="July"> July </option>
                <option value="August"> August </option>
                <option value="September"> September </option>
                <option value="October"> October </option>
                <option value="November"> November </option>
                <option value="December"> December </option>
              </select>
              <label class="form-sub-label" for="input_74_month" id="sublabel_74_month" style="min-height:13px" aria-hidden="false"> Month </label>
            </span>
            <span class="form-sub-label-container" style="vertical-align:top">
              <select name="q74_3rdDependents74[year]" id="input_74_year" class="form-dropdown" data-component="birthdate-year" aria-labelledby="label_74 sublabel_74_year">
                <option>  </option>
                <option value="2022"> 2022 </option>
                <option value="2021"> 2021 </option>
                <option value="2020"> 2020 </option>
                <option value="2019"> 2019 </option>
                <option value="2018"> 2018 </option>
                <option value="2017"> 2017 </option>
                <option value="2016"> 2016 </option>
                <option value="2015"> 2015 </option>
                <option value="2014"> 2014 </option>
                <option value="2013"> 2013 </option>
                <option value="2012"> 2012 </option>
                <option value="2011"> 2011 </option>
                <option value="2010"> 2010 </option>
                <option value="2009"> 2009 </option>
                <option value="2008"> 2008 </option>
                <option value="2007"> 2007 </option>
                <option value="2006"> 2006 </option>
                <option value="2005"> 2005 </option>
                <option value="2004"> 2004 </option>
                <option value="2003"> 2003 </option>
                <option value="2002"> 2002 </option>
                <option value="2001"> 2001 </option>
                <option value="2000"> 2000 </option>
                <option value="1999"> 1999 </option>
                <option value="1998"> 1998 </option>
                <option value="1997"> 1997 </option>
                <option value="1996"> 1996 </option>
                <option value="1995"> 1995 </option>
                <option value="1994"> 1994 </option>
                <option value="1993"> 1993 </option>
                <option value="1992"> 1992 </option>
                <option value="1991"> 1991 </option>
                <option value="1990"> 1990 </option>
                <option value="1989"> 1989 </option>
                <option value="1988"> 1988 </option>
                <option value="1987"> 1987 </option>
                <option value="1986"> 1986 </option>
                <option value="1985"> 1985 </option>
                <option value="1984"> 1984 </option>
                <option value="1983"> 1983 </option>
                <option value="1982"> 1982 </option>
                <option value="1981"> 1981 </option>
                <option value="1980"> 1980 </option>
                <option value="1979"> 1979 </option>
                <option value="1978"> 1978 </option>
                <option value="1977"> 1977 </option>
                <option value="1976"> 1976 </option>
                <option value="1975"> 1975 </option>
                <option value="1974"> 1974 </option>
                <option value="1973"> 1973 </option>
                <option value="1972"> 1972 </option>
                <option value="1971"> 1971 </option>
                <option value="1970"> 1970 </option>
                <option value="1969"> 1969 </option>
                <option value="1968"> 1968 </option>
                <option value="1967"> 1967 </option>
                <option value="1966"> 1966 </option>
                <option value="1965"> 1965 </option>
                <option value="1964"> 1964 </option>
               