Subversion Repositories SmartDukaan

Rev

Rev 10814 | Rev 11119 | Go to most recent revision | Show entire file | Ignore whitespace | Details | Blame | Last modification | View Log | RSS feed

Rev 10814 Rev 10950
Line 134... Line 134...
134 
			 <div id="error1" class="error_msg" style="display:none"></div>
 134 
			 <div id="error1" class="error_msg" style="display:none"></div>
135 
            <h3>We need these details for the purpose of insurance.</h3>
 135 
            <h3>We need these details for the purpose of insurance.</h3>
136 
            <label>Father's/Husband's Name :</label>
 136 
            <label>Father's/Husband's Name :</label>
137 
            <input id="gName"  type="text" />
 137 
            <input id="gName"  type="text" />
138 
            <label>Date of Birth (mm/dd/yyyy) :</label>
 138 
            <label>Date of Birth (mm/dd/yyyy) :</label>
139 
            <input type="text" id="bday" placeholder="mm/dd/yy">
 139 
            <input type="text" id="bday" placeholder="mm/dd/yyyy">
140 
            <input onclick="validateInsurance('1')" type="submit" name="submit" value='Submit' class="payment-btn tcenter btn" />
 140 
            <input onclick="validateInsurance('1')" type="submit" name="submit" value='Submit' class="payment-btn tcenter btn" />
141 
			</div><?php } ?>
 141 
			</div><?php } ?>
142 
			<div class="summary-head clearfix">order summary <!-- <span>+</span> --></div>
 142 
			<div class="summary-head clearfix">order summary <!-- <span>+</span> --></div>
143
143
144 
			<div class="order-summary">
 144 
			<div class="order-summary">