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Rev 27180 Rev 27181
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  		<div>
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  		<div>
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  			<div class="row">
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  			<div class="row">
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				<h4 class="modelHeaderCustom" style="font-size:22px;">Insurance Informartion</h4>
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				<h4 class="modelHeaderCustom" style="font-size:22px;">Insurance Informartion</h4>
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			</div>
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			</div>
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		</div>
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		</div>
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  			<div class="row" style="display:none" id="customer-address">
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			</div>
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  			<div class="row" style="display:none" id="billing-details">
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  			</div>
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	     	<div class="row mk_insurance_row" style="display:none">
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	     	<div class="row mk_insurance_row" style="display:none">
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				<div class="col-lg-3 form-group">
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				<div class="col-lg-3 form-group">
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				 <label for="gender">Gender</label>
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				 <label for="gender">Gender</label>
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					<select class="form-control input-sm" id="gender" name ="gender" placeholder="Gender">
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					<select class="form-control input-sm" id="gender" name ="gender" placeholder="Gender">
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						<option value="" disabled selected>Gender</option>
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						<option value="" disabled selected>Gender</option>
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					<input placeholder = "Date Of Birth" id="dateOfBirth" name="dateOfBirth" type="text" value="" class="form-control">
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					<input placeholder = "Date Of Birth" id="dateOfBirth" name="dateOfBirth" type="text" value="" class="form-control">
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				</div>
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				</div>
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			</div>
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			</div>
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     	</div>
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     	</div>
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     	<div class="col-lg-4 row">
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     	<div class="col-lg-4 row">
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		<div class="col-lg-1"></div>
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			<div class="col-lg-1"></div>
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		<div id="payment-details" style="background:white;background-color:white;" class="col-lg-10">
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			<div id="payment-details" style="background:white;background-color:white;" class="col-lg-10">
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			<h4 class="modelHeaderCustom" style="font-size:22px;">Payment Details</h4>
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				<h4 class="modelHeaderCustom" style="font-size:22px;">Payment Details</h4>
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			<div class="row">
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				<div class="row">
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				<div class="col-lg-7">
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					<div class="col-lg-7">
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					<h4>Total Amount :</h4>
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						<h4>Total Amount :</h4>
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				</div>
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					</div>
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				<div class="col-lg-5">
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					<div class="col-lg-5">
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					<input type="number" class="netPayableAmount form-control input-sm" name="" value="0" readonly>
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						<input type="number" class="netPayableAmount form-control input-sm" name="" value="0" readonly>
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				</div>
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					</div>
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			</div>
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				</div>
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			<div id="payment-option-id-amount-container" paymentOptionSize = $paymentOptions.size()>
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				<div id="payment-option-id-amount-container" paymentOptionSize = $paymentOptions.size()>
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			#set($a = 0)
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				#set($a = 0)
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			#set($b = $paymentOptions.size() - 1)
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				#set($b = $paymentOptions.size() - 1)
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			#set($range = [$a..$b])
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				#set($range = [$a..$b])
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			#foreach($index in $range)
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				#foreach($index in $range)
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			<div class="row">
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					<div class="row">
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				#set($paymentOption = $paymentOptions[$index])
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						#set($paymentOption = $paymentOptions[$index])
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				<div class="col-lg-7">
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						<div class="col-lg-7">
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					<h4>$paymentOption.getName() :</h4>
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							<h4>$paymentOption.getName() :</h4>
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				</div>
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						</div>
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				<div class="col-lg-5">
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						<div class="col-lg-5">
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					<input type="number" id="paymentOptionIdAmount${index}" name="paymentOptionIdAmount${index}"
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							<input type="number" id="paymentOptionIdAmount${index}" name="paymentOptionIdAmount${index}"
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					class="form-control paymentOptionAmount amount input-sm" value="0" paymentOptionId="$paymentOption.getId()">
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							class="form-control paymentOptionAmount amount input-sm" value="0" paymentOptionId="$paymentOption.getId()">
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				</div>
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						</div>
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			</div>
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					</div>
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			#end
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				#end
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			</div>
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				</div>
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			<div class="row">
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				<div class="row">
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				<div class="form-group col-lg-10">
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					<div class="form-group col-lg-10">
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					<button class="btn btn-block btn-primary order-checkout" type="submit">Create Order</button>
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						<button class="btn btn-block btn-primary order-checkout" type="submit">Create Order</button>
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					</div>
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				</div>
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				</div>
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			</div>
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			</div>
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		</div>
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		</div>
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	</div>
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	</div>
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	</div>
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</div>
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</div>
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#end
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#end
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</div>
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</div>
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</form>
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</form>
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</section>
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</section>