<?php
// Define variables and set to empty values
include('./Secure/Cred.php');

$plnbanda='';
$plnbandb='';
$plntpa='';
$plnbandc='';
$plnbandd='';
$xdogroupoplan='Individual';
$xdogroupoplan2='Individual';
$grp = 'Employee ID';
$xdoreadonly='';
$reqicon='';
$formreqrequired='form-input';
$classreq='form-line';
$cmpvalu='Health Assur';
if ($_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, $company_codex, $groupplanx) = mysqli_fetch_array($m_queues,MYSQLI_NUM))
{       
    $cmpvalu=$companyx;     
    $lnkvalu=$linkx;
    $xdogroupoplan=$groupplanx;
    $comcod = $company_codex;  
}

// Handle form submission
if ($_SERVER["REQUEST_METHOD"] == "POST") {
    
    // Get the last enrollment serial number from the database
    $query = "SELECT (`enrollment_serial_no`) FROM (`web_app_enrollee_data`) ORDER BY id DESC LIMIT 1";
    $result = conn($query);

    if ($result && $result->num_rows > 0) {
        $lastEnrollmentSerial = $result->fetch_assoc()['enrollment_serial_no'];
        // Increment the last enrollment serial number by 1
        $enrollmentSerialno = $lastEnrollmentSerial + 1;
    } else {
        // If there are no records in the database, start with a default value
        $enrollmentSerialno = 1000;
    }
    
    // File upload handling
    $targetDir = "uploads/"; // Directory where files will be uploaded
    $imageFileType = strtolower(pathinfo($_FILES["q99_passport"]["name"], PATHINFO_EXTENSION));
    $hmoId = $_POST['q110_hmoId'] . $enrollmentSerialno; // Assuming q110_hmoId contains the HMO ID

    // Set the target file name to HMO ID + enrollment serial number + extension
    $targetFile = $targetDir .$enrollmentSerialno . '.' . $imageFileType;

    $uploadOk = 1;

    // Check file size
    if ($_FILES["q99_passport"]["size"] > 500000) {
        echo "Sorry, your file is too large.";
        $uploadOk = 0;
    }

    // Allow only certain file formats
    if ($imageFileType != "jpg" && $imageFileType != "png" && $imageFileType != "jpeg"
        && $imageFileType != "gif") {
        echo "Sorry, only JPG, JPEG, PNG & GIF files are allowed.";
        $uploadOk = 0;
    }

    // Check if $uploadOk is set to 0 by an error
    if ($uploadOk == 0) {
        echo "Sorry, your file was not uploaded.";
    // if everything is ok, try to upload file
    } else {
        if (move_uploaded_file($_FILES["q99_passport"]["tmp_name"], $targetFile)) {
            echo "The file " . basename($_FILES["q99_passport"]["name"]) . " has been uploaded.";
        } else {
            echo "Sorry, there was an error uploading your file.";
        }
    }

    $companyName = $_POST['q98_companyName'];
    $surname = $_POST['q4_surname'];
    $firstName = $_POST['q26_firstName'];
    $middleName = $_POST['q27_middleName'];
    $gender = $_POST['q22_gender'];
    $phoneNumber = $_POST['q23_phoneNumber23'];
    $emailAddress = $_POST['q24_emailAddress'];
    $dateOfBirth = $_POST['q9_dateOf']['day'] . '/' . $_POST['q9_dateOf']['month'] . '/' . $_POST['q9_dateOf']['year'];
    $groupOfPlan = $_POST['q106_groupOf'];
    $typeOfPlan = $_POST['q30_typeOf30'];
    $streetAddress = $_POST['q20_address']['addr_line1'];
    $streetAddress2 = $_POST['q20_address']['addr_line2'];
    $city = $_POST['q20_address']['city'];
    $state = $_POST['q20_address']['state'];
    $lga = $_POST['q20_address']['postal'];
    $employeeId = $_POST['q29_employeeId'];
    $hospitals = $_POST['q31_hospitals'];
    $genotype = $_POST['q_genotype'];
    $bloodGroup = $_POST['q_bloodgroup'];
    $allergies = $_POST['q_allergies'];
    $haspreexistingcondition = $_POST['q_Preextcon'];
    $preexistingcondition = $_POST['q_Preextconans'];
    $hassurgicalhistory = $_POST['q_surgicalque'];
    $surgicalHistory = $_POST['q_surgical'];
    $current_date = date("Y-m-d H:i:s");
    $fileLink = 'https://healthassur.com/enrollment/'.$targetFile;

    // Insert new company data into the database, including file link
    $m_errs = conn("INSERT INTO `web_app_enrollee_data` ( `id` , `enrollment_serial_no`, `company_name` , `surname`, `first_name`, `middle_name`, `gender` , `phone_number` , `email_address`, `date_of_birth`, `group_of_plan`, `type_of_plan` , `hmo_id`, `address_street` , `address_city`, `address_state`, `lga`, `employee_id` , `hospitals` , `genotype`, `blood_group`, `allergies`, `has_pre_existing_condition`, `pre_existing_condition`, `has_surgical_history`, `surgical_history`, `Passport_link`, `newchanges`, 'changedate` ) VALUES ( NULL , '$enrollmentSerialno', '$companyName', '$surname', '$firstName', '$middleName', '$gender', '$phoneNumber', '$emailAddress', '$dateOfBirth', '$groupOfPlan', '$typeOfPlan', '$hmoId', '$streetAddress', '$city', '$state', '$lga', '$employeeId', '$hospitals', '$genotype', '$bloodGroup', '$allergies', '$haspreexistingcondition', '$preexistingcondition', '$hassurgicalhistory', '$surgicalHistory', '$fileLink', 'yes', '$current_date');");

    if ($m_errs === TRUE) {
        // Redirect to an external link
        header("Location: ./success.html");
        exit(); // Make sure no other output is sent
    } else {
        // Display error message
        echo "Error: " . $m_errs;
    }
}
    
	$m_queues1 = conn("SELECT state, location, provider_name FROM (`web_app_provider_list`) WHERE `provider_category` like 'TPA%';");
	while(list($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="Flex Plan"> Flex Plan </option>
				<option value="Executive Plan"> Executive Plan </option>
				<option value="Upper Plan"> Upper Plan </option>
				<option value="Business Plan"> Business Plan </option>
				<option value="Club Plan"> Club Plan </option>
				<option value="Social Plan"> Social Paln </option>';
    
    if($cmpvalu=='CAPITALFIELD INVESTMENT GROUP LIMITED'){
		$planinput30='<option value="Diamond Plan"> Diamond Plan </option>
					  <option value="Silver Plan"> Silver Plan </option>'; 
		 }
    
		 if($lnkvalu=='1714832570418378090R'){
		$planinput30='<option value="Standard Plan"> TSHIP_CUA </option>';
		$grp = 'Student ID';
		 }
?>

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<body>
<form class="jotform-form" action<?= htmlspecialchars($_SERVER["PHP_SELF"]) ?>" 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" data-layout="full">
          <div style="text-align:center"><img alt="Image" loading="lazy" class="form-image" style="border:0" src=images/Red-logo.png tabindex="0" 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"><?php echo $cmpvalu;?> 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" data-layout="full">
          <div id="text_48" class="form-html" data-component="text" tabindex="0">
            <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 always-hidden" data-type="control_textbox" id="id_118"><label class="form-label form-label-left form-label-auto" id="label_118" for="input_118"> Enrollment SerialNo </label>
        <div id="cid_118" class="form-input always-hidden" data-layout="half"> <input type="text" id="input_118" name="q118_enrollmentSerialno" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" value="" data-component="textbox" aria-labelledby="label_118" /> </div>
        <div id="cid_118" class="form-input always-hidden" data-layout="half"> <input type="text" id="input_118b" name="q118_enrollmentSerialno" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" value="" data-component="textbox" aria-labelledby="label_118" /> </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" data-layout="half"> <input type="text" id="input_98" name="q98_companyName" data-type="input-textbox" class="form-readonly form-textbox validate[required]" data-defaultvalue="FEDERAL INLAND REVENUE SERVICE (FIRS)" style="width:310px" size="310" 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" data-layout="half"> <input type="text" id="input_4" name="q4_surname" data-type="input-textbox" class="form-textbox validate[required]" data-defaultvalue="" style="width:310px" size="310" 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" data-layout="half"> <input type="text" id="input_26" name="q26_firstName" data-type="input-textbox" class="form-textbox validate[required]" data-defaultvalue="" style="width:310px" size="310" 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" data-layout="half"> <input type="text" id="input_27" name="q27_middleName" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" 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" data-layout="half"> <select class="form-dropdown validate[required]" id="input_22" name="q22_gender" style="width:310px" data-component="dropdown" required="" aria-label="Gender">
            <option value="">Please Select</option>
            <option value="Male">Male</option>
            <option value="Female">Female</option>
            
          </select> </div>
      </li>
      <li class="form-line jf-required" data-type="control_textbox" id="id_23"><label class="form-label form-label-left form-label-auto" id="label_23" for="input_23"> Phone Number<span class="form-required">*</span> </label>
        <div id="cid_23" class="form-input jf-required" data-layout="half"> <input type="text" id="input_23_full" name="q23_phoneNumber23" data-type="input-textbox" class="form-textbox validate[required]" data-defaultvalue="" style="width:310px" size="310" value="" placeholder=" " data-component="textbox" aria-labelledby="label_23" /> </div>
      </li>
      <li class="form-line jf-required" data-type="control_textbox" id="id_24"><label class="form-label form-label-left form-label-auto" id="label_24" for="input_24"> Email Address<span class="form-required">*</span> </label>
        <div id="cid_24" class="form-input jf-required" data-layout="half"> <input type="text" id="input_24" name="q24_emailAddress" data-type="input-textbox" class="form-textbox validate[required]" data-defaultvalue="" style="width:310px" size="310" value="" placeholder=" " data-component="textbox" aria-labelledby="label_24" /> </div>
      </li>
     <!-- <li class="form-line jf-required" data-type="control_email" id="id_24"><label class="form-label form-label-left form-label-auto" id="label_24" for="input_24"> E-mail Address<span class="form-required">*</span> </label>
        <div id="cid_24" class="form-input jf-required" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"><input type="email" id="input_24" name="q24_emailAddress" class="form-textbox validate[Email]" data-defaultvalue="" style="width:310px" size="310" value="" placeholder="ex: myname@example.com" data-component="email" aria-labelledby="label_24 sublabel_input_24" /><label class="form-sub-label" for="input_24" id="sublabel_input_24" style="min-height:13px" aria-hidden="false">example@example.com</label></span> </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" data-layout="full">
          <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="01">1</option>
                <option value="02">2</option>
                <option value="03">3</option>
                <option value="04">4</option>
                <option value="05">5</option>
                <option value="06">6</option>
                <option value="07">7</option>
                <option value="08">8</option>
                <option value="09">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="01">January</option>
                <option value="02">February</option>
                <option value="03">March</option>
                <option value="04">April</option>
                <option value="05">May</option>
                <option value="06">June</option>
                <option value="07">July</option>
                <option value="08">August</option>
                <option value="09">September</option>
                <option value="10">October</option>
                <option value="11">November</option>
                <option value="12">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="2023">2023</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_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" data-layout="full">
          <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" aria-describedby="label_106" 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>  
           <!-- </span><span class="form-radio-item" style="clear:left"><span class="dragger-item"></span><input type="radio" aria-describedby="label_106" 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">Individual</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" data-layout="half"> <select class="form-dropdown validate[required]" id="input_30" name="q30_typeOf30" style="width:310px" data-component="dropdown" required="" aria-label="Type of Plan" onchange="get_Enrollee_Code()">
        <option value="">  </option>
            <?php echo $planinput30; ?>
          </select> </div>
      </li>
      <li class="form-line always-hidden" data-type="control_textbox" id="id_110"><label class="form-label form-label-left form-label-auto" id="label_110" for="input_110"> HMO ID </label>
        <div id="cid_110" class="form-input always-hidden" data-layout="half"> <input type="text" id="input_110" name="q110_hmoId" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" value="HA/<?php echo $comcod.'/';?>" data-component="textbox" aria-labelledby="label_110" /> </div>
        
      </li>
      <li class="form-line jf-required" data-type="control_address" id="id_20" data-compound-hint=",,,,Please Select,,Please Select,"><label class="form-label form-label-left form-label-auto" id="label_20" for="input_20_addr_line1"> Home Address<span class="form-required">*</span> </label>
        <div id="cid_20" class="form-input jf-required" data-layout="full">
          <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" data-defaultvalue="" autoComplete="section-input_20 address-line1" 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-street-line jsTest-address-lineField"><span class="form-sub-label-container" style="vertical-align:top"><input type="text" id="input_20_addr_line2" name="q20_address[addr_line2]" class="form-textbox form-address-line" data-defaultvalue="" autoComplete="section-input_20 address-line2" value="" data-component="address_line_2" aria-labelledby="label_20 sublabel_20_addr_line2" /><label class="form-sub-label" for="input_20_addr_line2" id="sublabel_20_addr_line2" style="min-height:13px" aria-hidden="false">Street Address Line 2</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" data-defaultvalue="" autoComplete="section-input_20 address-level2" 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" data-defaultvalue="" autoComplete="section-input_20 address-level1" 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" data-defaultvalue="" autoComplete="section-input_20 postal-code" 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">LGA</label></span></span></div>
          </div>
        </div>
      </li>
      <li class="form-line" data-type="control_textbox" id="id_29"><label class="form-label form-label-left form-label-auto" id="label_29" for="input_29"> <?=$grp;?> <span class ="form-required">
            <?=$reqicon;?>
        </span> </label>
        <div id="cid_29" class="<?=$formreqrequired;?>" data-layout="half"> <input type="text" id="input_29" name="q29_employeeId" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" value="" placeholder=" " data-component="textbox" aria-labelledby="label_29" /> </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" data-layout="half"> 
            <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:310px" 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:13px" aria-hidden="false">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 the displayed hospital list* </br>
                </label></span> </div>
      </li>
      <li class="form-line jf-required" data-type="control_dropdown" id="id_genotype"><label class="form-label form-label-left form-label-auto" id="label_genotype" for="input_genotype"> Genotype<span class="form-required">*</span> </label>
        <div id="cid_genotype" class="form-input jf-required" data-layout="half"> <select class="form-dropdown validate[required]" id="input_genotype" name="q_genotype" style="width:310px" data-component="dropdown" required="" aria-label="Gender">
            <option value="">Please Select</option>
            <option value="AA">AA</option>
            <option value="AC">AC</option>
            <option value="AS">AS</option>
            <option value="CC">CC</option>
            <option value="SC">SC</option>
            <option value="SS">SS</option>
            
          </select> </div>
      </li>
      <li class="form-line jf-required" data-type="control_dropdown" id="id_bloodgroup"><label class="form-label form-label-left form-label-auto" id="label_bloodgroup" for="input_bloodgroup"> Blood Group<span class="form-required">*</span> </label>
        <div id="cid_bloodgroup" class="form-input jf-required" data-layout="half"> <select class="form-dropdown validate[required]" id="input_bloodgroup" name="q_bloodgroup" style="width:310px" data-component="dropdown" required="" aria-label="Gender">
            <option value="">Please Select</option>
            <option value="A+">A+</option>
            <option value="A-">A-</option>
            <option value="B+">B+</option>
            <option value="B-">B-</option>
            <option value="AB+">AB-</option>
            <option value="AB_">AB+</option>
            <option value="O+">O+</option>
            <option value="O-">O-</option>
            
          </select> </div>
      </li>
      <li class="form-line jf-required" data-type="control_textbox" id="id_allergies"><label class="form-label form-label-left form-label-auto" id="label_allergies" for="input_allergies"> Allergies<span class="form-required">*</span> </label>
        <div id="cid_allergies" class="form-input jf-required" data-layout="half"> <input type="text" id="input_allergies" name="q_allergies" data-type="input-textbox" class="form-textbox validate[required]" data-defaultvalue="" style="width:310px" size="310" value="" placeholder=" " data-component="textbox" aria-labelledby="label_allergies" /> </div>
      </li>
      
      <li class="form-line jf-required" data-type="control_dropdown" id="id_Preextcon"><label class="form-label form-label-left form-label-auto" id="label_Preextcon" for="input_Preextcon"> Any Pre-Existing Condition?<span class="form-required">*</span> </label>
        <div id="cid_Preextcon" class="form-input jf-required" data-layout="half"> <select class="form-dropdown validate[required]" id="input_Preextcon" name="q_Preextcon" style="width:310px" data-component="dropdown" required="" aria-label="Gender">
            <option value="">Please Select</option>
            <option value="Yes">Yes</option>
            <option value="No">No</option>
          </select> </div>
      </li>
      
      <li class="form-line" data-type="control_textbox" id="id_Preextconans"><label class="form-label form-label-left form-label-auto" id="label_Preextconans" for="Preextconans"> If yes? Pre-Existing Condition <span class ="form-required">
            <?=$reqicon;?>
        </span> </label>
        <div id="cid_Preextconans" class="<?=$formreqrequired;?>" data-layout="half"> <input type="text" id="input_Preextconans" name="q_Preextconans" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" value="" placeholder=" eg. hypertension, diabetes, asthma , etc" data-component="textbox" aria-labelledby="label_Preextconans" /> </div>
      </li>
      
      <li class="form-line jf-required" data-type="control_dropdown" id="id_surgicalque"><label class="form-label form-label-left form-label-auto" id="label_surgicalque" for="input_surgicalque"> Any Surgical History?<span class="form-required">*</span> </label>
        <div id="cid_surgicalque" class="form-input jf-required" data-layout="half"> <select class="form-dropdown validate[required]" id="input_surgicalque" name="q_surgicalque" style="width:310px" data-component="dropdown" required="" aria-label="surgicalque">
            <option value="">Please Select</option>
            <option value="Yes">Yes</option>
            <option value="No">No</option>
          </select> </div>
      </li>
      
      <li class="form-line" data-type="control_textbox" id="id_surgical"><label class="form-label form-label-left form-label-auto" id="label_surgical" for="input_surgical"> If yes? Surgical History<span class="form-required>"></span> </label>
        <div id="cid_surgical" class="<?=$formreqrequired;?>" data-layout="half"> <input type="text" id="input_surgical" name="q_surgical" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" value="" placeholder=" " data-component="textbox" aria-labelledby="label_surgical" /> </div>
      
       <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 form-field-hidden" style="display:none;" data-type="control_button" id="id_117">
        <div id="cid_117" class="form-input-wide" data-layout="full">
          <div data-align="auto" class="form-buttons-wrapper form-buttons-auto   jsTest-button-wrapperField"><button id="input_117" type="submit" class="form-submit-button submit-button jf-form-buttons jsTest-submitField" data-component="button" onclick "process_form.php" data-content="">Submit</button></div>
        </div>
      </li>
      <li id="cid_116" class="form-input-wide" data-type="control_pagebreak">
        <div class="form-pagebreak" data-component="pagebreak">
          <div class="form-pagebreak-back-container"><button id="form-pagebreak-back_116" type="button" class="form-pagebreak-back  jf-form-buttons" data-component="pagebreak-back">Back</button></div>
          <div class="form-pagebreak-next-container"><button id="form-pagebreak-next_116" type="button" class="form-pagebreak-next  jf-form-buttons" data-component="pagebreak-next">Next</button></div>
          <div style="clear:both" class="pageInfo form-sub-label" id="pageInfo_116"></div>
        </div>
      </li>
    </ul>
    <ul class="form-section page-section" style="display:none;">
      <li class="form-line" data-type="control_divider" id="id_34">
        <div id="cid_34" class="form-input-wide" data-layout="full">
          <div class="divider" data-component="divider" style="border-bottom-width:1px;border-bottom-style:solid;border-color:#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" data-layout="full">
          <div id="text_35" class="form-html" data-component="text" tabindex="0">
            <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" data-layout="half"> <input type="text" id="input_36" name="q36_spousesSurname" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" 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" data-layout="half"> <input type="text" id="input_37" name="q37_spousesFirst" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" 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" data-layout="half"> <input type="text" id="input_38" name="q38_spousesMiddle" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" 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_full"> Spouse's Phone Number </label>
        <div id="cid_41" class="form-input" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"><input type="tel" id="input_41_full" name="q41_spousesPhone[full]" data-type="mask-number" class="mask-phone-number form-textbox validate[Fill Mask]" data-defaultvalue="" autoComplete="section-input_41 tel-national" style="width:310px" data-masked="true" value="" placeholder="(000) 000-0000" data-component="phone" aria-labelledby="label_41" /></span> </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" data-layout="full">
          <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="2023">2023</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" data-layout="half"> <select class="form-dropdown" id="input_87" name="q87_spousesGender" style="width:310px" data-component="dropdown" aria-label="Spouse&#x27;s Gender">
            <option value="">Please Select</option>
            <option value="Male">Male</option>
            <option value="Female">Female</option>
            
          </select> </div>
      </li>
      <li class="form-line always-hidden" data-type="control_textbox" id="id_111"><label class="form-label form-label-left form-label-auto" id="label_111" for="input_111"> Spouse's HMO ID </label>
        <div id="cid_111" class="form-input always-hidden" data-layout="half"> <input type="text" id="input_111" name="q111_spousesHmo" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" value="" data-component="textbox" aria-labelledby="label_111" /> </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" data-layout="half"> <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">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" data-layout="full">
          <div class="jfQuestion-fields" data-wrapper-react="true">
            <div class="jfField isFilled">
              <div class="jfUpload-wrapper">
                <div class="jfUpload-container">
                  <div class="jfUpload-button-container">
                    <div class="jfUpload-button" aria-hidden="true" tabindex="0" style="display:none" data-version="v2">Browse Files<div class="jfUpload-heading forDesktop">Drag and drop files here</div>
                      <div class="jfUpload-heading forMobile">Choose a file</div>
                    </div>
                  </div>
                </div>
                <div class="jfUpload-files-container">
                  <div class="validate[multipleUpload]"><input type="file" id="input_100" name="q100_spousesPassport[]" multiple="" class="form-upload-multiple" data-imagevalidate="yes" data-file-accept="jpg, jpeg, png, gif" data-file-maxsize="10240" data-file-minsize="0" data-file-limit="" data-component="fileupload" aria-label="Browse Files" /></div>
                </div>
              </div><span class="form-sub-label-container" style="vertical-align:top"><label class="form-sub-label" for="input_100" id="sublabel_input_100" style="min-height:13px" aria-hidden="false">Select passport photo from your device.</label></span>
            </div><span style="display:none" class="cancelText">Cancel</span><span style="display:none" class="ofText">of</span>
          </div>
        </div>
      </li>
      <li class="form-line" data-type="control_divider" id="id_45">
        <div id="cid_45" class="form-input-wide" data-layout="full">
          <div class="divider" data-component="divider" style="border-bottom-width:1px;border-bottom-style:solid;border-color:#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" data-layout="full">
          <div id="text_46" class="form-html" data-component="text" tabindex="0">
            <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" data-layout="full">
          <div id="text_49" class="form-html" data-component="text" tabindex="0">
            <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" data-layout="half"> <input type="text" id="input_50" name="q50_1stDependents" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" 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" data-layout="half"> <input type="text" id="input_51" name="q51_1stDependents51" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" 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" data-layout="half"> <input type="text" id="input_52" name="q52_1stDependents52" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" 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_full"> 1st Dependent's Phone Number </label>
        <div id="cid_54" class="form-input" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"><input type="tel" id="input_54_full" name="q54_1stDependents54[full]" data-type="mask-number" class="mask-phone-number form-textbox validate[Fill Mask]" data-defaultvalue="" autoComplete="section-input_54 tel-national" style="width:310px" data-masked="true" value="" placeholder="(000) 000-0000" data-component="phone" aria-labelledby="label_54" /></span> </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" data-layout="full">
          <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="2023">2023</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" data-layout="half"> <select class="form-dropdown" id="input_89" name="q89_1stDependents89" style="width:310px" data-component="dropdown" aria-label="1st Dependent&#x27;s Gender">
            <option value="">Please Select</option>
            <option value="Male">Male</option>
            <option value="Female">Female</option>
            
          </select> </div>
      </li>
      <li class="form-line always-hidden" data-type="control_textbox" id="id_112"><label class="form-label form-label-left form-label-auto" id="label_112" for="input_112"> 1st Dependent's HMO ID </label>
        <div id="cid_112" class="form-input always-hidden" data-layout="half"> <input type="text" id="input_112" name="q112_1stDependents112" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" value="" data-component="textbox" aria-labelledby="label_112" /> </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" data-layout="half"> <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">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" data-layout="full">
          <div class="jfQuestion-fields" data-wrapper-react="true">
            <div class="jfField isFilled">
              <div class="jfUpload-wrapper">
                <div class="jfUpload-container">
                  <div class="jfUpload-button-container">
                    <div class="jfUpload-button" aria-hidden="true" tabindex="0" style="display:none" data-version="v2">Browse Files<div class="jfUpload-heading forDesktop">Drag and drop files here</div>
                      <div class="jfUpload-heading forMobile">Choose a file</div>
                    </div>
                  </div>
                </div>
                <div class="jfUpload-files-container">
                  <div class="validate[multipleUpload]"><input type="file" id="input_101" name="q101_1stDependents101[]" multiple="" class="form-upload-multiple" data-imagevalidate="yes" data-file-accept="jpg, jpeg, png, gif" data-file-maxsize="10240" data-file-minsize="0" data-file-limit="" data-component="fileupload" aria-label="Browse Files" /></div>
                </div>
              </div><span class="form-sub-label-container" style="vertical-align:top"><label class="form-sub-label" for="input_101" id="sublabel_input_101" style="min-height:13px" aria-hidden="false">Select passport photo from your device.</label></span>
            </div><span style="display:none" class="cancelText">Cancel</span><span style="display:none" class="ofText">of</span>
          </div>
        </div>
      </li>
      <li class="form-line" data-type="control_text" id="id_59">
        <div id="cid_59" class="form-input-wide" data-layout="full">
          <div id="text_59" class="form-html" data-component="text" tabindex="0">
            <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" data-layout="half"> <input type="text" id="input_60" name="q60_2ndDependents" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" 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" data-layout="half"> <input type="text" id="input_61" name="q61_2ndDependents61" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" 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" data-layout="half"> <input type="text" id="input_62" name="q62_2ndDependents62" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" 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_full"> 2nd Dependent's Phone Number </label>
        <div id="cid_64" class="form-input" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"><input type="tel" id="input_64_full" name="q64_2ndDependents64[full]" data-type="mask-number" class="mask-phone-number form-textbox validate[Fill Mask]" data-defaultvalue="" autoComplete="section-input_64 tel-national" style="width:310px" data-masked="true" value="" placeholder="(000) 000-0000" data-component="phone" aria-labelledby="label_64" /></span> </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" data-layout="full">
          <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="2023">2023</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" data-layout="half"> <select class="form-dropdown" id="input_91" name="q91_2ndDependents91" style="width:310px" data-component="dropdown" aria-label="2nd Dependent&#x27;s Gender">
            <option value="">Please Select</option>
            <option value="Male">Male</option>
            <option value="Female">Female</option>
            
          </select> </div>
      </li>
      <li class="form-line always-hidden" data-type="control_textbox" id="id_113"><label class="form-label form-label-left form-label-auto" id="label_113" for="input_113"> 2nd Dependent's HMO ID </label>
        <div id="cid_113" class="form-input" data-layout="half"> <input type="text" id="input_113" name="q113_2ndDependents113" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" value="" data-component="textbox" aria-labelledby="label_113" /> </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" data-layout="half"> <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">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" data-layout="full">
          <div class="jfQuestion-fields" data-wrapper-react="true">
            <div class="jfField isFilled">
              <div class="jfUpload-wrapper">
                <div class="jfUpload-container">
                  <div class="jfUpload-button-container">
                    <div class="jfUpload-button" aria-hidden="true" tabindex="0" style="display:none" data-version="v2">Browse Files<div class="jfUpload-heading forDesktop">Drag and drop files here</div>
                      <div class="jfUpload-heading forMobile">Choose a file</div>
                    </div>
                  </div>
                </div>
                <div class="jfUpload-files-container">
                  <div class="validate[multipleUpload]"><input type="file" id="input_102" name="q102_2ndDependents102[]" multiple="" class="form-upload-multiple" data-imagevalidate="yes" data-file-accept="jpg, jpeg, png, gif" data-file-maxsize="10240" data-file-minsize="0" data-file-limit="" data-component="fileupload" aria-label="Browse Files" /></div>
                </div>
              </div><span class="form-sub-label-container" style="vertical-align:top"><label class="form-sub-label" for="input_102" id="sublabel_input_102" style="min-height:13px" aria-hidden="false">Select passport photo from your device.</label></span>
            </div><span style="display:none" class="cancelText">Cancel</span><span style="display:none" class="ofText">of</span>
          </div>
        </div>
      </li>
      <li class="form-line" data-type="control_text" id="id_68">
        <div id="cid_68" class="form-input-wide" data-layout="full">
          <div id="text_68" class="form-html" data-component="text" tabindex="0">
            <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" data-layout="half"> <input type="text" id="input_69" name="q69_3rdDependents" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" 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" data-layout="half"> <input type="text" id="input_70" name="q70_3rdDependents70" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" 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" data-layout="half"> <input type="text" id="input_71" name="q71_3rdDependents71" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" 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_full"> 3rd Dependent's Phone Number </label>
        <div id="cid_73" class="form-input" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"><input type="tel" id="input_73_full" name="q73_3rdDependents73[full]" data-type="mask-number" class="mask-phone-number form-textbox validate[Fill Mask]" data-defaultvalue="" autoComplete="section-input_73 tel-national" style="width:310px" data-masked="true" value="" placeholder="(000) 000-0000" data-component="phone" aria-labelledby="label_73" /></span> </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" data-layout="full">
          <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="2023">2023</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_74_year" id="sublabel_74_year" style="min-height:13px" aria-hidden="false">Year</label></span></div>
        </div>
      </li>
      <li class="form-line" data-type="control_dropdown" id="id_93"><label class="form-label form-label-left form-label-auto" id="label_93" for="input_93"> 3rd Dependent's Gender </label>
        <div id="cid_93" class="form-input" data-layout="half"> <select class="form-dropdown" id="input_93" name="q93_3rdDependents93" style="width:310px" data-component="dropdown" aria-label="3rd Dependent&#x27;s Gender">
            <option value="">Please Select</option>
            <option value="Male">Male</option>
            <option value="Female">Female</option>
            
          </select> </div>
      </li>
      <li class="form-line always-hidden" data-type="control_textbox" id="id_114"><label class="form-label form-label-left form-label-auto" id="label_114" for="input_114"> 3rd Dependent's HMO ID </label>
        <div id="cid_114" class="form-input always-hidden" data-layout="half"> <input type="text" id="input_114" name="q114_3rdDependents114" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" value="" data-component="textbox" aria-labelledby="label_114" /> </div>
      </li>
      <li class="form-line" data-type="control_dropdown" id="id_94"><label class="form-label form-label-left form-label-auto" id="label_94" for="input_94"> 3rd Dependent's Hospitals </label>
        <div id="cid_94" class="form-input" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"><input<?=$xdoreadonly;?> list="input_94b" class="form-dropdown" id="input_94" name="q94_3rdDependents94" style="width:150px" data-component="dropdown" aria-labelledby="label_94 sublabel_input_94">
              <datalist id="input_94b">
  <option value="">
  <option value="">
</datalist><label class="form-sub-label" for="input_94" id="sublabel_input_94" style="min-height:13px" aria-hidden="false">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_103"><label class="form-label form-label-left form-label-auto" id="label_103" for="input_103"> 3rd Dependent's Passport </label>
        <div id="cid_103" class="form-input" data-layout="full">
          <div class="jfQuestion-fields" data-wrapper-react="true">
            <div class="jfField isFilled">
              <div class="jfUpload-wrapper">
                <div class="jfUpload-container">
                  <div class="jfUpload-button-container">
                    <div class="jfUpload-button" aria-hidden="true" tabindex="0" style="display:none" data-version="v2">Browse Files<div class="jfUpload-heading forDesktop">Drag and drop files here</div>
                      <div class="jfUpload-heading forMobile">Choose a file</div>
                    </div>
                  </div>
                </div>
                <div class="jfUpload-files-container">
                  <div class="validate[multipleUpload]"><input type="file" id="input_103" name="q103_3rdDependents103[]" multiple="" class="form-upload-multiple" data-imagevalidate="yes" data-file-accept="jpg, jpeg, png, gif" data-file-maxsize="10240" data-file-minsize="0" data-file-limit="" data-component="fileupload" aria-label="Browse Files" /></div>
                </div>
              </div><span class="form-sub-label-container" style="vertical-align:top"><label class="form-sub-label" for="input_103" id="sublabel_input_103" style="min-height:13px" aria-hidden="false">Select passport photo from your device.</label></span>
            </div><span style="display:none" class="cancelText">Cancel</span><span style="display:none" class="ofText">of</span>
          </div>
        </div>
      </li>
      <li class="form-line" data-type="control_text" id="id_77">
        <div id="cid_77" class="form-input-wide" data-layout="full">
          <div id="text_77" class="form-html" data-component="text" tabindex="0">
            <p style="text-align: left;"><span style="font-size: 12pt; color: #ff0000;"><strong><strong>DEPENDENT 4<br /></strong></strong></span></p>
          </div>
        </div>
      </li>
      <li class="form-line" data-type="control_textbox" id="id_78"><label class="form-label form-label-left form-label-auto" id="label_78" for="input_78"> 4th Dependent's Surname </label>
        <div id="cid_78" class="form-input" data-layout="half"> <input type="text" id="input_78" name="q78_4thDependents" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" value="" placeholder=" " data-component="textbox" aria-labelledby="label_78" /> </div>
      </li>
      <li class="form-line" data-type="control_textbox" id="id_79"><label class="form-label form-label-left form-label-auto" id="label_79" for="input_79"> 4th Dependent's First Name </label>
        <div id="cid_79" class="form-input" data-layout="half"> <input type="text" id="input_79" name="q79_4thDependents79" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" value="" placeholder=" " data-component="textbox" aria-labelledby="label_79" /> </div>
      </li>
      <li class="form-line" data-type="control_textbox" id="id_80"><label class="form-label form-label-left form-label-auto" id="label_80" for="input_80"> 4th Dependent's Middle Name </label>
        <div id="cid_80" class="form-input" data-layout="half"> <input type="text" id="input_80" name="q80_4thDependents80" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" value="" placeholder=" " data-component="textbox" aria-labelledby="label_80" /> </div>
      </li>
      <li class="form-line" data-type="control_phone" id="id_82"><label class="form-label form-label-left form-label-auto" id="label_82" for="input_82_full"> 4th Dependent's Phone Number </label>
        <div id="cid_82" class="form-input" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"><input type="tel" id="input_82_full" name="q82_4thDependents82[full]" data-type="mask-number" class="mask-phone-number form-textbox validate[Fill Mask]" data-defaultvalue="" autoComplete="section-input_82 tel-national" style="width:310px" data-masked="true" value="" placeholder="(000) 000-0000" data-component="phone" aria-labelledby="label_82" /></span> </div>
      </li>
      <li class="form-line" data-type="control_birthdate" id="id_83"><label class="form-label form-label-left form-label-auto" id="label_83" for="input_83"> 4th Dependent's Date of Birth </label>
        <div id="cid_83" class="form-input" data-layout="full">
          <div data-wrapper-react="true"><span class="form-sub-label-container" style="vertical-align:top"><select name="q83_4thDependents83[day]" id="input_83_day" class="form-dropdown" data-component="birthdate-day" aria-labelledby="label_83 sublabel_83_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_83_day" id="sublabel_83_day" style="min-height:13px" aria-hidden="false">Day</label></span><span class="form-sub-label-container" style="vertical-align:top"><select name="q83_4thDependents83[month]" id="input_83_month" class="form-dropdown" data-component="birthdate-month" aria-labelledby="label_83 sublabel_83_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_83_month" id="sublabel_83_month" style="min-height:13px" aria-hidden="false">Month</label></span><span class="form-sub-label-container" style="vertical-align:top"><select name="q83_4thDependents83[year]" id="input_83_year" class="form-dropdown" data-component="birthdate-year" aria-labelledby="label_83 sublabel_83_year">
                <option></option>
                <option value="2023">2023</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_83_year" id="sublabel_83_year" style="min-height:13px" aria-hidden="false">Year</label></span></div>
        </div>
      </li>
      <li class="form-line" data-type="control_dropdown" id="id_95"><label class="form-label form-label-left form-label-auto" id="label_95" for="input_95"> 4th Dependent's Gender </label>
        <div id="cid_95" class="form-input" data-layout="half"> <select class="form-dropdown" id="input_95" name="q95_4thDependents95" style="width:310px" data-component="dropdown" aria-label="4th Dependent&#x27;s Gender">
            <option value="">Please Select</option>
            <option value="Male">Male</option>
            <option value="Female">Female</option>
            
          </select> </div>
      </li>
      <li class="form-line always-hidden" data-type="control_textbox" id="id_115"><label class="form-label form-label-left form-label-auto" id="label_115" for="input_115"> 4th Dependent's HMO ID </label>
        <div id="cid_115" class="form-input always-hidden" data-layout="half"> <input type="text" id="input_115" name="q115_4thDependents115" data-type="input-textbox" class="form-textbox" data-defaultvalue="" style="width:310px" size="310" value="" data-component="textbox" aria-labelledby="label_115" /> </div>
      </li>
      <li class="form-line" data-type="control_dropdown" id="id_96"><label class="form-label form-label-left form-label-auto" id="label_96" for="input_96"> 4th Dependent's Hospitals </label>
        <div id="cid_96" class="form-input" data-layout="half"> <span class="form-sub-label-container" style="vertical-align:top"><input<?=$xdoreadonly;?> list="input_96b" class="form-dropdown" id="input_96" name="q96_4thDependents96" style="width:150px" data-component="dropdown" aria-labelledby="label_96 sublabel_input_96">
              <datalist id="input_96b">
  <option value="">
  <option value="">
</datalist>
<label class="form-sub-label" for="input_96" id="sublabel_input_96" style="min-height:13px" aria-hidden="false">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_104"><label class="form-label form-label-left form-label-auto" id="label_104" for="input_104"> 4th Dependent's Passport </label>
        <div id="cid_104" class="form-input" data-layout="full">
          <div class="jfQuestion-fields" data-wrapper-react="true">
            <div class="jfField isFilled">
              <div class="jfUpload-wrapper">
                <div class="jfUpload-container">
                  <div class="jfUpload-button-container">
                    <div class="jfUpload-button" aria-hidden="true" tabindex="0" style="display:none" data-version="v2">Browse Files<div class="jfUpload-heading forDesktop">Drag and drop files here</div>
                      <div class="jfUpload-heading forMobile">Choose a file</div>
                    </div>
                  </div>
                </div>
                <div class="jfUpload-files-container">
                  <div class="validate[multipleUpload]"><input type="file" id="input_104" name="q104_4thDependents104[]" multiple="" class="form-upload-multiple" data-imagevalidate="yes" data-file-accept="jpg, jpeg, png, gif" data-file-maxsize="10240" data-file-minsize="0" data-file-limit="" data-component="fileupload" aria-label="Browse Files" /></div>
                </div>
              </div><span class="form-sub-label-container" style="vertical-align:top"><label class="form-sub-label" for="input_104" id="sublabel_input_104" style="min-height:13px" aria-hidden="false">Select passport photo from your device.</label></span>
            </div><span style="display:none" class="cancelText">Cancel</span><span style="display:none" class="ofText">of</span>
          </div>
        </div>
      </li>
      <li class="form-line" data-type="control_checkbox" id="id_86"><label class="form-label form-label-left form-label-auto" id="label_86" for="input_86"> By clicking SUBMIT you are agreeing to share your information with us. </label>
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          <div class="form-multiple-column" data-columncount="2" role="group" aria-labelledby="label_86" data-component="checkbox"><span class="form-checkbox-item"><span class="dragger-item"></span><input type="checkbox" aria-describedby="label_86" class="form-checkbox" id="input_86_0" name="q86_name86[]" value="I agree." /><label id="label_input_86_0" for="input_86_0">I agree.</label></span></div>
        </div>
      </li>
      <li class="form-line" data-type="control_button" id="id_2">
        <div id="cid_2" class="form-input-wide" data-layout="full">
          <div data-align="center" class="form-buttons-wrapper form-buttons-center   jsTest-button-wrapperField"><span> </span><button id="input_print_2" type="button" class="form-submit-print form-submit-button-reports-400 jf-form-buttons" data-component="button"><img src="https://cdn.jotfor.ms/images/printer.png" style="vertical-align:middle" alt="Print" /><span id="span_print_2" class="span_print">Print Form</span></button><button id="input_2" type="submit" class="form-submit-button form-submit-button-reports-400 submit-button jf-form-buttons jsTest-submitField" data-component="button" data-content="">Submit Form</button></div>
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var plnidlp='<?php echo addslashes($plnidlp);?>';
var plnidlc='<?php echo addslashes($plnidlc);?>';
var changedfoundation='<?php echo addslashes($changedfoundation);?>';
var platinumtincan='<?php echo addslashes($platinumtincan);?>';
var goldplustincan='<?php echo addslashes($goldplustincan);?>';
var plndiagnostics='';
var plnent='';
var plngoldc='';
var plndental='';
var plnoptical='';
var plnall='';
var plnnil='<option value=""></option>';
document.getElementById('input_30').addEventListener('change', function() {
	var patrq = this.value;
	var patrv = document.getElementById('input_98').value;
	document.getElementById('input_31b').innerHTML= plnbandd;
	document.getElementById('input_58b').innerHTML= plnnil+plnbandd;
	document.getElementById('input_90b').innerHTML= plnnil+plnbandd;
	document.getElementById('input_92b').innerHTML= plnnil+plnbandd;
	document.getElementById('input_94b').innerHTML= plnnil+plnbandd;
	document.getElementById('input_96b').innerHTML= plnnil+plnbandd;
	if (patrv.trim() =='CHANGED FOUNDATION'){
		document.getElementById('input_31b').innerHTML= changedfoundation;
	document.getElementById('input_58b').innerHTML= plnnil+changedfoundation;
	document.getElementById('input_90b').innerHTML= plnnil+changedfoundation;
	document.getElementById('input_92b').innerHTML= plnnil+changedfoundation;
	document.getElementById('input_94b').innerHTML= plnnil+changedfoundation;
	document.getElementById('input_96b').innerHTML= plnnil+changedfoundation;
	document.getElementById('input_30b').value='Standard Plan';
	}else if (patrv.trim() =='BRIDGEGAP CONSULTS LTD (OPPO)'){
		document.getElementById('input_31b').innerHTML= plnbridgegap;
	document.getElementById('input_58b').innerHTML= plnnil+plnbridgegap;
	document.getElementById('input_90b').innerHTML= plnnil+plnbridgegap;
	document.getElementById('input_92b').innerHTML= plnnil+plnbridgegap;
	document.getElementById('input_94b').innerHTML= plnnil+plnbridgegap;
	document.getElementById('input_96b').innerHTML= plnnil+plnbridgegap;
	document.getElementById('input_30b').value='Standard Plan';
	}/*else if (patrv.trim() =='CAPITALFIELD INVESTMENT GROUP LIMITED'){
	document.getElementById('input_31b').innerHTML= plntpa+plnbanda+plnbandb+plnbandc+plnbandd;
	document.getElementById('input_58b').innerHTML= plnnil+plntpa+plnbanda+plnbandb+plnbandc+plnbandd;
	document.getElementById('input_90b').innerHTML= plnnil+plntpa+plnbanda+plnbandb+plnbandc+plnbandd;
	document.getElementById('input_92b').innerHTML= plnnil+plntpa+plnbanda+plnbandb+plnbandc+plnbandd;
	document.getElementById('input_94b').innerHTML= plnnil+plntpa+plnbanda+plnbandb+plnbandc+plnbandd;
	document.getElementById('input_96b').innerHTML= plnnil+plntpa+plnbanda+plnbandb+plnbandc+plnbandd;
	}*/else if (patrq =='IDLC') {
	document.getElementById('input_31b').innerHTML= plnnil+plnidlp+plnidlc;
	document.getElementById('input_58b').innerHTML= plnnil+plnidlp+plnidlc;
	document.getElementById('input_90b').innerHTML= plnnil+plnidlp+plnidlc;
	document.getElementById('input_92b').innerHTML= plnnil+plnidlp+plnidlc;
	document.getElementById('input_94b').innerHTML= plnnil+plnidlp+plnidlc;
	document.getElementById('input_96b').innerHTML= plnnil+plnidlp+plnidlc;
	}else if (patrq =='IDLP') {
	document.getElementById('input_31b').innerHTML= plnnil+plnidlp;
	document.getElementById('input_58b').innerHTML= plnnil+plnidlp;
	document.getElementById('input_90b').innerHTML= plnnil+plnidlp;
	document.getElementById('input_92b').innerHTML= plnnil+plnidlp;
	document.getElementById('input_94b').innerHTML= plnnil+plnidlp;
	document.getElementById('input_96b').innerHTML= plnnil+plnidlp;
	}else if (patrq =='Platinum Plan') {
		document.getElementById('input_31b').innerHTML= plntpa+plnbanda+plnbandb+plnbandc+plnbandd;
	document.getElementById('input_58b').innerHTML= plnnil+plntpa+plnbanda+plnbandb+plnbandc+plnbandd;
	document.getElementById('input_90b').innerHTML= plnnil+plntpa+plnbanda+plnbandb+plnbandc+plnbandd;
	document.getElementById('input_92b').innerHTML= plnnil+plntpa+plnbanda+plnbandb+plnbandc+plnbandd;
	document.getElementById('input_94b').innerHTML= plnnil+plntpa+plnbanda+plnbandb+plnbandc+plnbandd;
	document.getElementById('input_96b').innerHTML= plnnil+plntpa+plnbanda+plnbandb+plnbandc+plnbandd;
	}else if (patrq.trim() =='Diamond Plan'){
		document.getElementById('input_31b').innerHTML= plntpa+plnbanda+plnbandb+plnbandc+plnbandd;
	document.getElementById('input_58b').innerHTML= plnnil+plntpa+plnbanda+plnbandb+plnbandc+plnbandd;
	document.getElementById('input_90b').innerHTML= plnnil+plntpa+plnbanda+plnbandb+plnbandc+plnbandd;
	document.getElementById('input_92b').innerHTML= plnnil+plntpa+plnbanda+plnbandb+plnbandc+plnbandd;
	document.getElementById('input_94b').innerHTML= plnnil+plntpa+plnbanda+plnbandb+plnbandc+plnbandd;
	document.getElementById('input_96b').innerHTML= plnnil+plntpa+plnbanda+plnbandb+plnbandc+plnbandd;
	}else if (patrq.trim() =='Gold Plus Plan'){
		document.getElementById('input_31b').innerHTML= plntpa+plnbandb+plnbandc+plnbandd;
	document.getElementById('input_58b').innerHTML= plnnil+plntpa+plnbandb+plnbandc+plnbandd;
	document.getElementById('input_90b').innerHTML= plnnil+plntpa+plnbandb+plnbandc+plnbandd;
	document.getElementById('input_92b').innerHTML= plnnil+plntpa+plnbandb+plnbandc+plnbandd;
	document.getElementById('input_94b').innerHTML= plnnil+plntpa+plnbandb+plnbandc+plnbandd;
	document.getElementById('input_96b').innerHTML= plnnil+plntpa+plnbandb+plnbandc+plnbandd;
	}else if (patrq.trim() =='Gold Plan'){
		document.getElementById('input_31b').innerHTML= plntpa+plnbandc+plnbandd;
	document.getElementById('input_58b').innerHTML= plnnil+plntpa+plnbandc+plnbandd;
	document.getElementById('input_90b').innerHTML= plnnil+plntpa+plnbandc+plnbandd;
	document.getElementById('input_92b').innerHTML= plnnil+plntpa+plnbandc+plnbandd;
	document.getElementById('input_94b').innerHTML= plnnil+plntpa+plnbandc+plnbandd;
	document.getElementById('input_96b').innerHTML= plnnil+plntpa+plnbandc+plnbandd;
	}else if (patrq.trim() =='TPA'){
		document.getElementById('input_31').innerHTML= plntpa+plnbanda+plnbandb+plnbandc+plnbandd;
	document.getElementById('input_58b').innerHTML= plnnil+plntpa+plnbanda+plnbandb+plnbandc+plnbandd;
	document.getElementById('input_90b').innerHTML= plnnil+plntpa+plnbanda+plnbandb+plnbandc+plnbandd;
	document.getElementById('input_92b').innerHTML= plnnil+plntpa+plnbanda+plnbandb+plnbandc+plnbandd;
	document.getElementById('input_94b').innerHTML= plnnil+plntpa+plnbanda+plnbandb+plnbandc+plnbandd;
	document.getElementById('input_96b').innerHTML= plnnil+plntpa+plnbanda+plnbandb+plnbandc+plnbandd;
	}else if (patrv.trim() =='TINCAN ISLAND CONTAINERS TERMINAL (TICT)' && patrq.trim() =='Platinum Plan'){
		document.getElementById('input_31b').innerHTML= platinumtincan;
	document.getElementById('input_58b').innerHTML= plnnil+platinumtincan;
	document.getElementById('input_90b').innerHTML= plnnil+platinumtincan;
	document.getElementById('input_92b').innerHTML= plnnil+platinumtincan;
	document.getElementById('input_94b').innerHTML= plnnil+platinumtincan;
	document.getElementById('input_96b').innerHTML= plnnil+platinumtincan;
	document.getElementById('input_30b').value=patrq.trim();
	}else if (patrv.trim() =='TINCAN ISLAND CONTAINERS TERMINAL (TICT)' && patrq.trim() =='Gold Plus Plan'){
		document.getElementById('input_31b').innerHTML= goldplustincan;
	document.getElementById('input_58b').innerHTML= plnnil+goldplustincan;
	document.getElementById('input_90b').innerHTML= plnnil+goldplustincan;
	document.getElementById('input_92b').innerHTML= plnnil+goldplustincan;
	document.getElementById('input_94b').innerHTML= plnnil+goldplustincan;
	document.getElementById('input_96b').innerHTML= plnnil+goldplustincan;
	document.getElementById('input_30b').value=patrq.trim();
	}
	
	var options = $('datalist#input_31b option');
    var arr = options.map(function(_, o) {
        return {
            t: $(o).text(),
            v: o.value
        };
    }).get();
    arr.sort(function(o1, o2) {
        return o1.t > o2.t ? 1 : o1.t < o2.t ? -1 : 0;
    });
    options.each(function(i, o) {
        console.log(i);
        o.value = arr[i].v;
        $(o).text(arr[i].t);
    });
 //2   
    var options = $('datalist#input_58b option');
    var arr = options.map(function(_, o) {
        return {
            t: $(o).text(),
            v: o.value
        };
    }).get();
    arr.sort(function(o1, o2) {
        return o1.t > o2.t ? 1 : o1.t < o2.t ? -1 : 0;
    });
    options.each(function(i, o) {
        console.log(i);
        o.value = arr[i].v;
        $(o).text(arr[i].t);
    });
    //3
    var options = $('datalist#input_90b option');
    var arr = options.map(function(_, o) {
        return {
            t: $(o).text(),
            v: o.value
        };
    }).get();
    arr.sort(function(o1, o2) {
        return o1.t > o2.t ? 1 : o1.t < o2.t ? -1 : 0;
    });
    options.each(function(i, o) {
        console.log(i);
        o.value = arr[i].v;
        $(o).text(arr[i].t);
    });
    //4
    var options = $('datalist#input_92b option');
    var arr = options.map(function(_, o) {
        return {
            t: $(o).text(),
            v: o.value
        };
    }).get();
    arr.sort(function(o1, o2) {
        return o1.t > o2.t ? 1 : o1.t < o2.t ? -1 : 0;
    });
    options.each(function(i, o) {
        console.log(i);
        o.value = arr[i].v;
        $(o).text(arr[i].t);
    });
    //5
    var options = $('datalist#input_94b option');
    var arr = options.map(function(_, o) {
        return {
            t: $(o).text(),
            v: o.value
        };
    }).get();
    arr.sort(function(o1, o2) {
        return o1.t > o2.t ? 1 : o1.t < o2.t ? -1 : 0;
    });
    options.each(function(i, o) {
        console.log(i);
        o.value = arr[i].v;
        $(o).text(arr[i].t);
    });
    //6
    var options = $('datalist#input_96b option');
    var arr = options.map(function(_, o) {
        return {
            t: $(o).text(),
            v: o.value
        };
    }).get();
    arr.sort(function(o1, o2) {
        return o1.t > o2.t ? 1 : o1.t < o2.t ? -1 : 0;
    });
    options.each(function(i, o) {
        console.log(i);
        o.value = arr[i].v;
        $(o).text(arr[i].t);
    });
});

</script>

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