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Rev 26828 Rev 27180
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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 class="row" style="display:none" id="customer-address">
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			</div>
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			</div>
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  			<div class="row" style="display:none" id="billing-details">
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  			<div class="row" style="display:none" id="billing-details">
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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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					 <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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							<option value="" disabled selected>Gender</option>
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							<option value="1" selected>Male</option>
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							<option value="2" selected>Female</option>
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		                </select>
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					</div>
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					<div class="col-lg-3 form-group">
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					 <label for="dateOfBirth">Date Of Birth</label>
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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 class="row mk_insurance_row" style="display:none">
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				<div class="col-lg-3 form-group">
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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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						<option value="" disabled selected>Gender</option>
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						<option value="1" selected>Male</option>
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						<option value="2" selected>Female</option>
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	                </select>
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				</div>
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				<div class="col-lg-3 form-group">
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				 <label for="dateOfBirth">Date Of Birth</label>
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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 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>