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LifeQT_Req.html
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LifeQT_Req.html
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<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="UTF-8">
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<!--jQuery-->
<script src="https://code.jquery.com/jquery-3.5.1.slim.min.js" integrity="sha256-4+XzXVhsDmqanXGHaHvgh1gMQKX40OUvDEBTu8JcmNs=" crossorigin="anonymous"></script>
<!--Bootstrap CDN-->
<link rel="stylesheet" href="https://stackpath.bootstrapcdn.com/bootstrap/4.4.1/css/bootstrap.min.css" integrity="sha384-Vkoo8x4CGsO3+Hhxv8T/Q5PaXtkKtu6ug5TOeNV6gBiFeWPGFN9MuhOf23Q9Ifjh" crossorigin="anonymous">
<!--google font-->
<link rel="preconnect" href="https://fonts.gstatic.com">
<link href="https://fonts.googleapis.com/css2?family=Lora&display=swap" rel="stylesheet">
<!--Font Awesome-->
<link rel="stylesheet" href="https://use.fontawesome.com/releases/v5.15.1/css/all.css" integrity="sha384-vp86vTRFVJgpjF9jiIGPEEqYqlDwgyBgEF109VFjmqGmIY/Y4HV4d3Gp2irVfcrp" crossorigin="anonymous">
<script type="text/javascript" src="//translate.google.com/translate_a/element.js?cb=googleTranslateElementInit"></script>
<!--StyleSheet-->
<link rel="stylesheet" href="/css/style-sheet.css">
<title>JGI - Life</title>
<link rel='icon' type='image/jpg' href="/images/Logo/FaviconLogo.jpg">
</head>
<body>
<!--Body-->
<!--Alert with phone numbers and Navbar-->
<nav>
<div id="menu">
</nav>
<br><br>
<!--Life Quote Request-->
<div class="container-md">
<h2 class='autoReq'>Life Insurance Request</h2>
<br>
<form action="https://formsubmit.co/docs@jgiatx.com" method="POST">
<input type="hidden" name="_next" value="https://jgarciains.com/ThankYou.html">
<input type="hidden" name="_captcha" value="false">
<input type="hidden" name="_subject" value="New Life Insurance Quote Request">
<p><h5>Primary Insured</h5></p>
<div class="form-row">
<div class="form-group col-md-6">
<label for="name">First Name</label>
<input type="name" class="form-control" name="First-Name" id="firstName">
</div>
<div class="form-group col-md-6">
<label for="lastName">Last Name</label>
<input type="lastName" class="form-control" name="Last-Name" id="lastName">
</div>
</div>
<div class="form-row">
<div class="form-group col-md-6">
<label for="email">Email</label>
<input type="email" class="form-control" name="Email" id="email">
</div>
<div class="form-group col-md-6">
<label for="phoneNumber">Phone Number</label>
<input type="phoneNumber" class="form-control" name="Phone-Number" id="phoneNumber">
</div>
</div>
<br><hr><br>
<p><h5>Mailing Address</h5></p>
<div class="form-group">
<label for="inputAddress">Property Location Address</label>
<input type="text" class="form-control" id="inputAddress" name="Mailing-Address" placeholder="1234 Main St">
</div>
<div class="form-row">
<div class="form-group col-md-6">
<label for="inputCity">City</label>
<input type="text" class="form-control" name="Mailing-City" id="inputCity">
</div>
<div class="form-group col-md-4">
<label for="inputState">State</label>
<input id="inputState" class="form-control" name="Mailing-State" id="inputZip">
</div>
<div class="form-group col-md-2">
<label for="inputZip">Zip</label>
<input type="text" class="form-control" name="Mailing-Zip" id="inputZip">
</div>
</div>
<br><hr><br>
<p><h5>Insurance Information</h5></p>
<div class="form-group">
<label for="inputAddress">Insurance Type?</label>
<ul>
<p>Term Life: provides coverage at a fixed rate of payments for a limited period of time, the relevant term.</p>
<p>Whole Life: policy which is guaranteed to remain in force for the insured's entire lifetime, provided required premiums are paid, or to the maturity date.</p>
</ul>
<input type="text" class="form-control" id="inputAddress" name="Insurance-Type" placeholder="Term or Whole Life" >
</div>
<div class="form-row">
<div class="form-group col-md-3">
<label for="stateIssued">Desired Coverage</label>
<input type="stateIssued" class="form-control" name="Desired-Coverage" id="stateIssued">
</div>
<div class="form-group col-md-3">
<label for="dob">Date of Birth</label>
<input type="dob" class="form-control" name="DOB" id="dob">
</div>
<div class="form-group col-md-3">
<label for="dlNumber">Height</label>
<input type="dlNumber" class="form-control" name="Height" id="dlNumber">
</div>
<div class="form-group col-md-3">
<label for="socialSecurity">Weight</label>
<input type="text" class="form-control" name="Weight" id="socialSecurity">
</div>
</div>
<br><hr><br>
<div class="form-group">
<label for="exampleFormControlTextarea1">Additional Information </label>
<textarea class="form-control" id="exampleFormControlTextarea1" name='Additional-Info' rows="2"></textarea>
</div>
<br><hr><br>
<div class='btAutoForm'>
<div class="d-grid gap-2 d-md-block">
<button class="btn btn-info" type="button"><a href="HomeInsurance.html">Back</a></button>
<button class="btn btn-info" type="submit">Submit</button>
</div>
</div>
<br>
</div>
</form>
</div>
<br><br><br>
<div class='container-fluid'>
<div class="text-center">
<p>Please Note that coverage cannot be bound via quote request form</p>
</div>
</div>
<br>
<!--Footer-->
<footer>
<div id='footer'></div>
</footer>
<!--my javascript code-->
<link rel="javascript" href="Public/js/script.js" />
<script src="https://ajax.googleapis.com/ajax/libs/jquery/3.5.1/jquery.min.js"></script>
<!--Bootstrap CDN jQuery-->
<!-- jQuery first, then Popper.js, then Bootstrap JS -->
<script src="https://code.jquery.com/jquery-3.4.1.slim.min.js" integrity="sha384-J6qa4849blE2+poT4WnyKhv5vZF5SrPo0iEjwBvKU7imGFAV0wwj1yYfoRSJoZ+n" crossorigin="anonymous"></script>
<script src="https://cdn.jsdelivr.net/npm/popper.js@1.16.0/dist/umd/popper.min.js" integrity="sha384-Q6E9RHvbIyZFJoft+2mJbHaEWldlvI9IOYy5n3zV9zzTtmI3UksdQRVvoxMfooAo" crossorigin="anonymous"></script>
<script src="https://stackpath.bootstrapcdn.com/bootstrap/4.4.1/js/bootstrap.min.js" integrity="sha384-wfSDF2E50Y2D1uUdj0O3uMBJnjuUD4Ih7YwaYd1iqfktj0Uod8GCExl3Og8ifwB6" crossorigin="anonymous"></script>
<script src="https://ajax.googleapis.com/ajax/libs/jquery/2.2.0/jquery.min.js"></script>
<script>
$(function(){
$("#menu").load("assets/components/headerNav.html");
});
</script>
<script>
$(function(){
$("#footer").load("assets/components/footer.html");
});
</script>
</body>
</html>