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AHCCorporateQuotes.aspx.exclude
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AHCCorporateQuotes.aspx.exclude
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<%@ Page Language="C#" AutoEventWireup="true" CodeFile="AHCCorporateQuotes.aspx.cs" Inherits="EPolicy.AHCCorporateQuotes" %>
<%@ Register TagPrefix="MaskedInput" Namespace="MaskedInput" Assembly="MaskedInput" %>
<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd">
<html>
<head>
<title>ePMS | electronic Policy Manager Solution</title>
<meta name="GENERATOR" Content="Microsoft Visual Studio 7.0">
<meta name="CODE_LANGUAGE" Content="C#">
<meta name="vs_defaultClientScript" content="JavaScript">
<meta name="vs_targetSchema" content="http://schemas.microsoft.com/intellisense/ie5">
<link rel="stylesheet" href="css/jquery-ui-1.7.2.custom.css" type="text/css" />
<script type="text/javascript" src="js/jquery-1.3.2.min.js"></script>
<script type="text/javascript" src="js/jquery-ui-1.7.2.custom.min.js"></script>
<script src="js/load.js" type="text/javascript"></script>
<style type="text/css">
.toggler {
width: 276px;
height: 16px;
}
#button {
padding: .5em 2em;
text-decoration: none;
}
#btnCloseEffect {
text-decoration: none;
}
#effect {
width: 455px;
height: 480px;
padding: 0.4em;
position: relative;
}
#effect h3 {
margin: 0;
padding: 0.4em;
text-align: center;
}
.ui-effects-transfer {
border: 2px dotted gray;
}
</style>
<style type="text/css">
#jq-books {
width: 200px;
float: right;
margin-right: 0
}
#jq-books li {
line-height: 1.25em;
margin: 1em 0 1.8em;
clear: left
}
#home-content-wrapper #jq-books a.jq-bookImg {
float: left;
margin-right: 10px;
width: 55px;
height: 70px
}
#jq-books h3 {
margin: 0 0 .2em 0
}
#home-content-wrapper #jq-books h3 a {
font-size: 1em;
color: black;
}
#home-content-wrapper #jq-books a.jq-buyNow {
font-size: 1em;
color: white;
display: block;
background: url(http://static.jquery.com/files/rocker/images/btn_blueSheen.gif) 50% repeat-x;
text-decoration: none;
color: #fff;
font-weight: bold;
padding: .2em .8em;
float: left;
margin-top: .2em;
}
</style>
<script>
function parseRate() {
var myString;
//for(i = 1;i <= document.form1.ddlPolicyClass.options.length ; i++)
//{
//myString = document.form1.ddlPolicyClass.options[1].value;
myString = document.form1.ddlPolicyClass.options[document.form1.ddlPolicyClass.selectedIndex].value;
var myRateList = myString.split("|");
//alert(myRateList[0]+"-"+myRateList[1])
document.form1.txtPrateID.value = myRateList[0];
document.form1.HIIsoCode.value = myRateList[1];
document.form1.HIClass.value = myRateList[2];
document.form1.HIRate1.value = myRateList[3];
document.form1.HIRate2.value = myRateList[4];
document.form1.HIRate3.value = myRateList[5];
document.form1.HIRate4.value = myRateList[6];
document.form1.txtIsoCode.value = myRateList[1];
document.form1.txtClass.value = myRateList[2];
document.form1.txtRate1.value = myRateList[3];
document.form1.txtRate2.value = myRateList[4];
document.form1.txtRate3.value = myRateList[5];
document.form1.txtRate4.value = myRateList[6];
// for(a = 0;a < myRateList.lenght; a++)
// {
// var Rate1 = myRateList[a];
// var startPos = Rate1.indexOf(',');
// var myValue = Rate1.substring(startPos, Rate1.lenght -startPos);
// //alert(myValue);
// document.form1.txtIsoCode.value = myValue;
// }
//}
}
</script>
</head>
<script type="text/javascript" src="js/jquery-1.3.2.min.js"></script>
<script type="text/javascript" src="js/jquery-ui-1.7.2.custom.min.js"></script>
<script type="text/javascript">
$(function() {
$('#<%= txtPriPolEffecDate1.ClientID %>').datepicker({
changeMonth: true,
changeYear: true
});
$('#<%= txtPriPolEffecDate2.ClientID %>').datepicker({
changeMonth: true,
changeYear: true
});
$('#<%= txtPriPolEffecDate3.ClientID %>').datepicker({
changeMonth: true,
changeYear: true
});
$('#<%= txtExcPolEffecDate1.ClientID %>').datepicker({
changeMonth: true,
changeYear: true
});
$('#<%= txtExcPolEffecDate2.ClientID %>').datepicker({
changeMonth: true,
changeYear: true
});
$('#<%= txtExcPolEffecDate3.ClientID %>').datepicker({
changeMonth: true,
changeYear: true
});
$('#<%= txtDateBirth.ClientID %>').datepicker({
changeMonth: true,
changeYear: true
});
$('#<%= txtPrimaryRetroDate.ClientID %>').datepicker({
changeMonth: true,
changeYear: true
});
$('#<%= txtExcessRetroDate.ClientID %>').datepicker({
changeMonth: true,
changeYear: true
});
});
function ShowDateTimePicker() {
$('#<%= txtPriPolEffecDate1.ClientID %>').datepicker('show');
}
function ShowDateTimePicker2() {
$('#<%= txtPriPolEffecDate2.ClientID %>').datepicker('show');
}
function ShowDateTimePicker3() {
$('#<%= txtPriPolEffecDate3.ClientID %>').datepicker('show');
}
function ShowDateTimePicker4() {
$('#<%= txtExcPolEffecDate1.ClientID %>').datepicker('show');
}
function ShowDateTimePicker5() {
$('#<%= txtExcPolEffecDate2.ClientID %>').datepicker('show');
}
function ShowDateTimePicker6() {
$('#<%= txtExcPolEffecDate3.ClientID %>').datepicker('show');
}
function ShowDateTimePicker7() {
$('#<%= txtDateBirth.ClientID %>').datepicker('show');
}
function ShowDateTimePicker8() {
$('#<%= txtPrimaryRetroDate.ClientID %>').datepicker('show');
}
//style="width: 316px; display:none"
function pageLoad() {
//sets initial state of the contactfinderdiv
//alert(jQuery('#HIState').val());
var state = jQuery('#HIState').val();
if (state == '1') {
$('#effect').css('display', 'block');
//$('#HIState').val('');
} else {
$('#effect').css('display', 'none');
}
$('.btnRate').click(function() {
$('.togglebox').show('slow');
});
$('.btnCloseEffect').click(function() {
$('.togglebox').hide('slow');
});
}
$(function() {
//run the currently selected effect
function runEffect() {
//get effect type from
//var selectedEffect = $('#effectTypes').val();
$('#HIState').val('1');
var selectedEffect = "blind";
//most effect types need no options passed by default
var options = {};
//run the effect
$("#effect").show(selectedEffect, options, 500, callback);
};
//callback function to bring a hidden box back
function callback() {
// setTimeout(function()
// {
// $("#effect:visible").removeAttr('style').hide().fadeOut();
// },
// 1000);
};
function CloseEffect() {
setTimeout(function() {
$('#HIState').val('0');
$("#effect:visible").removeAttr('style').hide().fadeOut();
},
10);
}
//set effect from select menu value
$("#button").click(function() {
runEffect();
return false;
});
$("#btnRate").click(function() {
runEffect();
return false;
});
$("#btnCloseEffect").click(function() {
CloseEffect();
return false;
});
$("#effect").hide();
});
</script>
<body onload="pageLoad()">
<form id="form1" runat="server">
<div>
<p>
<asp:PlaceHolder ID="Placeholder1" runat="server"></asp:PlaceHolder>
</p>
<div class="container-xl mb-4 p-18">
<div class="row">
<div class="col-md-6">
<asp:Label ID="Label21" runat="server">Application:</asp:Label>
<asp:Label ID="lblTaskControlID" runat="server"></asp:Label>
</div>
<div class="col-md-6 f-right">
<asp:Button ID="btnConvert" runat="server" class="btn-h-30 btn-bg-theme2 btn-r-4 mb-1" Text="Convert Excess" OnClick="btnConvert_Click" Visible="True" />
<asp:Button ID="btnPrint" runat="server" class="btn-h-30 btn-bg-theme2 btn-r-4 mb-1" Text="Print Quote" OnClick="btnPrint_Click" Visible="True" />
<asp:Button ID="btnConvertPrimary" runat="server" class="btn-h-30 btn-bg-theme2 btn-r-4 mb-1" Text="Convert Policy" OnClick="btnConvertPrimary_Click" />
<asp:Button ID="btnRate" runat="server" class="btn-h-30 btn-bg-theme2 btn-r-4 mb-1" Text="Rate" />
<asp:Button ID="BtnSave" runat="server" class="btn-h-30 btn-bg-theme2 btn-r-4 mb-1" OnClick="BtnSave_Click" Text="Save" />
<asp:Button ID="btnEdit" runat="server" class="btn-h-30 btn-bg-theme2 btn-r-4 mb-1" Text="Modify" OnClick="btnEdit_Click" />
<asp:Button ID="btnDelete" runat="server" class="btn-h-30 btn-bg-theme2 btn-r-4 mb-1" Text="Delete" OnClick="btnDelete_Click" />
<asp:Button ID="btnCancel" runat="server" class="btn-h-30 btn-bg-theme2 btn-r-4 mb-1" Text="Cancel" OnClick="btnCancel_Click" />
<asp:Button ID="BtnExit" runat="server" class="btn-h-30 btn-bg-theme2 btn-r-4 mb-1" Text="Exit" OnClick="BtnExit_Click" />
</div>
</div>
<div class="col-md-12">
<hr>
</div>
<div class="toggler">
<div id="effect" class="ui-widget-header ui-corner-all" style="display:none">
<asp:Panel ID="Panel1" runat="server">
<div class="col-md-12 f-center">
<asp:Label ID="Label49" runat="server" class="d-block" Text="Select Rate"></asp:Label>
<asp:RadioButton ID="RadioButton1" runat="server" Text="Rate" AutoPostBack="True" OnCheckedChanged="RadioButton1_CheckedChanged" />
<asp:RadioButton ID="RadioButton2" runat="server" Text="Excess" AutoPostBack="True" Visible="True" OnCheckedChanged="RadioButton2_CheckedChanged" />
<asp:Label ID="Label51" runat="server" class="d-block" Text="Retro Date:"></asp:Label>
<MaskedInput:MaskedTextBox ID="txtPrimaryRetroDate" runat="server" class="form-control mb-1 fs-txt-s w-25" IsDate="True" onclick="ShowDateTimePicker8();" AutoPostBack="True" OnTextChanged="txtPrimaryRetroDate_TextChanged"></MaskedInput:MaskedTextBox>
<asp:Label ID="Label56" runat="server" Text="Excess Retro Date:"></asp:Label>
<MaskedInput:MaskedTextBox ID="txtExcessRetroDate" runat="server" class="form-control mb-1 fs-txt-s w-25" IsDate="True" onclick="ShowDateTimePicker9();" AutoPostBack="True" OnTextChanged="txtExcessRetroDate_TextChanged"></MaskedInput:MaskedTextBox>
</div>
<div class="row">
<div class="col-md-4">
<asp:Label ID="Label63" runat="server" class="fs-lbl-s" Text="Rate"></asp:Label>
</div>
<div class="col-md-2">
<asp:Label ID="Label65" runat="server" class="fs-lbl-s" Text="Rate 1"></asp:Label>
</div>
<div class="col-md-2">
<asp:Label ID="Label66" runat="server" class="fs-lbl-s" Text="Rate 2"></asp:Label>
</div>
<div class="col-md-2">
<asp:Label ID="Label67" runat="server" class="fs-lbl-s" Text="Rate 3"></asp:Label>
</div>
<div class="col-md-2">
<asp:Label ID="Label68" runat="server" class="fs-lbl-s" Text="MCM Rate "></asp:Label>
</div>
</div>
<div class="row">
<div class="col-md-4">
<asp:DropDownList ID="ddlPrimaryLimits1" runat="server" class="form-select mb-1 fs-txt-s" AutoPostBack="True" OnSelectedIndexChanged="ddlPrimaryLimits1_SelectedIndexChanged" ForeColor="Black">
</asp:DropDownList>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtPRate1" runat="server" Font-Names="Tahoma" ReadOnly="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtPRate2" runat="server" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtPRate3" runat="server" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtPRate4" runat="server" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
</div>
<div class="row">
<div class="col-md-4">
<asp:Label ID="Label64" runat="server" class="fs-lbl-s" Text="Excess Rate"></asp:Label>
</div>
<div class="col-md-2">
<asp:Label ID="Label42" runat="server" class="fs-lbl-s" Text="Rate 1"></asp:Label>
</div>
<div class="col-md-2">
<asp:Label ID="Label43" runat="server" class="fs-lbl-s" Text="Rate 2"></asp:Label>
</div>
<div class="col-md-2">
<asp:Label ID="Label45" runat="server" class="fs-lbl-s" Text="Rate 3"></asp:Label>
</div>
<div class="col-md-2">
<asp:Label ID="Label44" runat="server" class="fs-lbl-s" Text="MCM Rate "></asp:Label>
</div>
</div>
<div class="row">
<div class="col-md-4">
<asp:DropDownList ID="ddlLimits" runat="server" class="form-select mb-1 fs-txt-s" AutoPostBack="True" OnSelectedIndexChanged="ddlLimits_SelectedIndexChanged">
</asp:DropDownList>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtRate1" runat="server" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtRate2" runat="server" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtRate3" runat="server" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtRate4" runat="server" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
</div>
<div class="col-md-12">
<asp:Label ID="Label62" runat="server" Text="Others Excess Rates:"></asp:Label>
</div>
<div class="row">
<div class="col-md-4">
<asp:DropDownList ID="ddlLimits2" runat="server" class="form-select mb-1 fs-txt-s" AutoPostBack="True" OnSelectedIndexChanged="ddlLimits_SelectedIndexChanged">
</asp:DropDownList>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtRate12" runat="server" ReadOnly="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtRate22" runat="server" ReadOnly="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtRate32" runat="server" ReadOnly="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtRate42" runat="server" ReadOnly="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
</div>
<div class="row">
<div class="col-md-4">
<asp:DropDownList ID="ddlLimits3" runat="server" class="form-select mb-1 fs-txt-s" AutoPostBack="True">
</asp:DropDownList>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtRate13" runat="server" ReadOnly="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtRate23" runat="server" ReadOnly="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtRate33" runat="server" ReadOnly="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtRate43" runat="server" ReadOnly="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
</div>
<div class="row">
<div class="col-md-4">
<asp:DropDownList ID="ddlLimits4" runat="server" class="form-select mb-1 fs-txt-s" AutoPostBack="True" OnSelectedIndexChanged="ddlLimits4_SelectedIndexChanged">
</asp:DropDownList>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtRate14" runat="server" ReadOnly="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtRate24" runat="server" ReadOnly="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtRate34" runat="server" ReadOnly="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtRate44" runat="server" ReadOnly="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
</div>
<div class="row">
<div class="col-md-4">
<asp:DropDownList ID="ddlLimits5" runat="server" class="form-select mb-1 fs-txt-s" AutoPostBack="True">
</asp:DropDownList>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtRate15" runat="server" ReadOnly="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtRate25" runat="server" ReadOnly="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtRate35" runat="server" ReadOnly="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtRate45" runat="server" ReadOnly="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
</div>
<div class="row">
<div class="col-md-4">
<asp:DropDownList ID="ddlLimits6" runat="server" class="form-select mb-1 fs-txt-s" utoPostBack="True">
</asp:DropDownList>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtRate16" runat="server" ReadOnly="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtRate26" runat="server" ReadOnly="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtRate36" runat="server" ReadOnly="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtRate46" runat="server" ReadOnly="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
</div>
<div class="row">
<div class="col-md-6">
<asp:Label ID="Label57" runat="server" class="fs-lbl-s" Text="Select Specialty:"></asp:Label>
<asp:DropDownList ID="ddPrimarylPolicyClass" class="form-select mb-1 fs-txt-s" runat="server" AutoPostBack="True" OnSelectedIndexChanged="ddlPolicyClass_SelectedIndexChanged1" Visible="True">
</asp:DropDownList>
<asp:Label ID="Label41" runat="server" class="fs-lbl-s" Text="Select Specialty:"></asp:Label>
<asp:DropDownList ID="ddlPolicyClass" class="form-select mb-1 fs-txt-s" runat="server" OnSelectedIndexChanged="ddlPolicyClass_SelectedIndexChanged1" Visible="True" AutoPostBack="True">
</asp:DropDownList>
</div>
<div class="col-md-6">
<asp:Label ID="Label46" runat="server" class="fs-lbl-s" Text="Iso Code:"></asp:Label>
<asp:TextBox ID="txtIsoCode" runat="server" ReadOnly="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
<asp:Label ID="Label47" runat="server" class="fs-lbl-s" Text="Class:"></asp:Label>
<asp:TextBox ID="txtClass" runat="server" ReadOnly="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
</div>
<div class="col-md-12">
<asp:Button ID="btnCloseEffect" runat="server" class="btn-h-30 btn-bg-theme2 btn-r-4" Text="Close" />
</div>
</div>
</div>
</asp:Panel>
<div class="col-md-12 mb-3">
<asp:Label ID="Label2" runat="server">I. PERSONAL INFORMATION</asp:Label>
</div>
<div class="row">
<div class="col-md-6">
<div class="row">
<div class="col-md-4">
<asp:Label ID="Label54" class="fs-lbl-s" runat="server" EnableViewState="False">*</asp:Label>
<asp:Label ID="lblGender" class="fs-lbl-s" runat="server" EnableViewState="False">Name:</asp:Label>
</div>
<div class="col-md-8">
<asp:TextBox ID="TxtFirstName" runat="server" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
</div>
<div class="row">
<div class="col-md-4">
<asp:Label ID="lblLastName2" class="fs-lbl-s" runat="server" EnableViewState="False">Middle:</asp:Label>
</div>
<div class="col-md-8">
<asp:TextBox ID="TxtInitial" runat="server" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
</div>
<div class="row">
<div class="col-md-4">
<asp:Label ID="lblBirthdate" class="fs-lbl-s" runat="server" EnableViewState="False">LastName:</asp:Label>
</div>
<div class="col-md-8">
<asp:TextBox ID="txtLastname1" runat="server" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
</div>
<div class="row">
<div class="col-md-4">
<asp:Label ID="Label55" class="fs-lbl-s" runat="server" EnableViewState="False">*</asp:Label>
<asp:Label ID="Label4" class="fs-lbl-s" runat="server" EnableViewState="False">LastName 2:</asp:Label>
</div>
<div class="col-md-8">
<asp:TextBox ID="txtLastname2" runat="server" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
</div>
<div class="row">
<div class="col-md-4">
<asp:Label ID="lblMaritalStatus" class="fs-lbl-s" runat="server" EnableViewState="False">Date of Birth:</asp:Label>
</div>
<div class="col-md-8">
<MaskedInput:MaskedTextBox ID="txtDateBirth" runat="server" class="form-control mb-1 fs-txt-s" onclick="ShowDateTimePicker7();" IsDate="True"></MaskedInput:MaskedTextBox>
</div>
</div>
<div class="row">
<div class="col-md-4">
<asp:Label ID="lblComments" class="fs-lbl-s" runat="server" EnableVi ewState="False">Place of Birth:</asp:Label>
</div>
<div class="col-md-8">
<asp:TextBox ID="txtBirthPlace" runat="server" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
</div>
<div class="row">
<div class="col-md-4">
<asp:Label ID="lblHouseIncome" class="fs-lbl-s" runat="server">Gender:</asp:Label>
</div>
<div class="col-md-8 mb-1">
<asp:RadioButtonList ID="rdoGender" runat="server" class="fs-lbl-s" RepeatDirection="Horizontal">
<asp:ListItem>Female</asp:ListItem>
<asp:ListItem>Male</asp:ListItem>
</asp:RadioButtonList>
</div>
</div>
<div class="row">
<div class="col-md-4">
<asp:Label ID="Label1" class="fs-lbl-s" runat="server" EnableViewState="False">Customer No.:</asp:Label>
</div>
<div class="col-md-8">
<asp:TextBox ID="TxtCustomerNo" runat="server" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
</div>
<div class="row">
<div class="col-md-4">
<asp:Label ID="Label50" class="fs-lbl-s" runat="server" EnableViewState="False">Status:</asp:Label>
</div>
<div class="col-md-8">
<asp:DropDownList ID="ddlStatus" class="form-select mb-1 fs-txt-s" runat="server">
</asp:DropDownList>
</div>
</div>
<div class="row">
<div class="col-md-4">
<asp:Label ID="Label52" class="fs-lbl-s" runat="server" EnableViewState="False">Agency:</asp:Label>
</div>
<div class="col-md-8">
<asp:DropDownList ID="ddlAgency" runat="server" class="form-select mb-1 fs-txt-s">
</asp:DropDownList>
</div>
</div>
<div class="row">
<div class="col-md-4">
<asp:Label ID="Label48" class="fs-lbl-s" runat="server">Comments:</asp:Label>
</div>
<div class="col-md-8">
<asp:TextBox ID="txtComments" runat="server" TextMode="MultiLine" class="form-control mb-1 fs-txt-s w-260 h-6"></asp:TextBox>
</div>
</div>
</div>
<div class="col-md-6">
<div class="row">
<div class="col-md-4">
<asp:Label ID="Label53" class="fs-lbl-s" runat="server" EnableViewState="False">Agent:</asp:Label>
</div>
<div class="col-md-8">
<asp:DropDownList ID="ddlAgent" runat="server" class="form-select mb-1 fs-txt-s">
</asp:DropDownList>
</div>
</div>
<div class="row">
<div class="col-md-4">
<asp:Label ID="Label6" class="fs-lbl-s" runat="server">Office Address:</asp:Label>
</div>
<div class="col-md-8">
<asp:TextBox ID="TxtAddrs1" runat="server" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
</div>
<div class="row">
<div class="col-md-4">
</div>
<div class="col-md-8">
<asp:TextBox ID="TxtAddrs2" runat="server" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
</div>
<div class="row">
<div class="col-md-4">
<asp:Label ID="Label7" class="fs-lbl-s" runat="server">City:</asp:Label>
</div>
<div class="col-md-8">
<div class="input-group mb-1">
<asp:TextBox ID="TxtCity" runat="server" class="form-control fs-txt-s"></asp:TextBox>
<asp:TextBox ID="TxtState" runat="server" class="form-control fs-txt-s"></asp:TextBox>
<MaskedInput:MaskedTextBox ID="TxtZip" runat="server" class="form-control fs-txt-s" IsDate="False" Mask="99999Z9999" MaxLength="10"></MaskedInput:MaskedTextBox>
</div>
</div>
</div>
<div class="row">
<div class="col-md-4">
<asp:Label ID="Label59" runat="server" class="fs-lbl-s" EnableViewState="False">*</asp:Label>
<asp:Label ID="Label3" runat="server" class="fs-lbl-s" EnableViewState="False">Office Phone:</asp:Label>
</div>
<div class="col-md-8">
<MaskedInput:MaskedTextBox ID="txtWorkPhone" class="form-control mb-1 fs-txt-s" runat="server" IsCurrency="False" IsDate="False" IsZipCode="False" Mask="(999) 999-9999" MaxLength="14"></MaskedInput:MaskedTextBox>
</div>
</div>
<div class="row">
<div class="col-md-4">
<asp:Label ID="lblLastName1" runat="server" class="fs-lbl-s" EnableViewState="False">Office Fax:</asp:Label>
</div>
<div class="col-md-8">
<MaskedInput:MaskedTextBox ID="TxtCellular" runat="server" class="form-control mb-1 fs-txt-s" IsCurrency="False" IsDate="False" IsZipCode="False" Mask="(999) 999-9999" MaxLength="14"></MaskedInput:MaskedTextBox>
</div>
</div>
<div class="row">
<div class="col-md-4">
<asp:Label ID="Label5" runat="server" class="fs-lbl-s" EnableViewState="False">E-mail:</asp:Label>
</div>
<div class="col-md-8">
<asp:TextBox ID="txtEmail" runat="server" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
</div>
<div class="row">
<div class="col-md-4">
<asp:Label ID="Label61" runat="server" class="fs-lbl-s" EnableViewState="False">*</asp:Label>
<asp:Label ID="Label8" runat="server" class="fs-lbl-s" EnableViewState="False">Cell Phone:</asp:Label>
</div>
<div class="col-md-8">
<MaskedInput:MaskedTextBox ID="txtHomePhone" runat="server" class="form-control mb-1 fs-txt-s" IsCurrency="False" IsDate="False" IsZipCode="False" Mask="(999) 999-9999" MaxLength="14"></MaskedInput:MaskedTextBox>
</div>
</div>
<div class="row">
<div class="col-md-4">
<asp:Label ID="Label151" runat="server" class="fs-lbl-s">License:</asp:Label>
</div>
<div class="col-md-8">
<asp:TextBox ID="txtLicense" runat="server" MaxLength="25" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
</div>
</div>
</div>
<div class="col-md-12">
<hr>
</div>
<asp:Label ID="lblSocialSecurity" runat="server" class="fs-lbl-s" EnableViewState="False" Visible="False">Social Security:</asp:Label>
<MaskedInput:MaskedTextBox ID="txtSocialSecurity" runat="server" class="form-control mb-1 fs-txt-s" IsCurrency="False" IsDate="False" IsZipCode="False" Mask="999-99-9999" Visible="false"></MaskedInput:MaskedTextBox>
<asp:Button ID="btnNextTop" runat="server" Text="Next >" OnClick="btnNextTop_Click" Visible="False" />
<div class="col-md-12 mb-3">
<asp:Label ID="lblTypeAddress1" runat="server">II. INSURANCE HISTORY</asp:Label>
</div>
<p>
<asp:Label ID="Label15" runat="server">2. Please provide the necessary information below with respect to your primary insurance coverage for</asp:Label>
<asp:Label ID="Label17" runat="server">the last three years, including the coverage in force as of the date of this application.</asp:Label>
</p>
<div class="row">
<div class="col-md-3">
<asp:Label ID="Label18" runat="server" class="fs-lbl-s" EnableViewState="False">Previous Carrier Name</asp:Label>
</div>
<div class="col-md-3">
<asp:Label ID="Label14" runat="server" class="fs-lbl-s" EnableViewState="False">Policy Effective Dates</asp:Label>
</div>
<div class="col-md-3">
<asp:Label ID="Label19" runat="server" class="fs-lbl-s" EnableViewState="False">Policy Limits</asp:Label>
</div>
<div class="col-md-3">
<asp:Label ID="Label20" runat="server" class="fs-lbl-s" EnableViewState="False">Policy No. Other Company</asp:Label>
</div>
</div>
<div class="row">
<div class="col-md-3">
<asp:TextBox ID="txtPriCarierName1" runat="server" MaxLength="75" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-3">
<asp:TextBox ID="txtPriPolEffecDate1" runat="server" onclick="ShowDateTimePicker();" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-3">
<asp:TextBox ID="txtPriPolLimits1" runat="server" MaxLength="50" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-3">
<asp:TextBox ID="txtPriClaims1" runat="server" MaxLength="50" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
</div>
<div class="row">
<div class="col-md-3">
<asp:TextBox ID="txtPriCarierName2" runat="server" MaxLength="75" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-3">
<MaskedInput:MaskedTextBox ID="txtPriPolEffecDate2" runat="server" class="form-control mb-1 fs-txt-s" onclick="ShowDateTimePicker2();" IsDate="True"></MaskedInput:MaskedTextBox>
</div>
<div class="col-md-3">
<asp:TextBox ID="txtPriPolLimits2" runat="server" MaxLength="50" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-3">
<asp:TextBox ID="txtPriClaims2" runat="server" MaxLength="50" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
</div>
<div class="row">
<div class="col-md-3">
<asp:TextBox ID="txtPriCarierName3" runat="server" MaxLength="75" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-3">
<MaskedInput:MaskedTextBox ID="txtPriPolEffecDate3" runat="server" class="form-control mb-1 fs-txt-s" onclick="ShowDateTimePicker3();" IsDate="True"></MaskedInput:MaskedTextBox>
</div>
<div class="col-md-3">
<asp:TextBox ID="txtPriPolLimits3" runat="server" MaxLength="50" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-3">
<asp:TextBox ID="txtPriClaims3" runat="server" MaxLength="50" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
</div>
<asp:Label ID="Label28" runat="server" Visible="True">3. Please provide the necessary information below with respect to your excess professional liability</asp:Label>
<asp:Label ID="Label29" runat="server" Visible="True">insurance coverage for the last three years, including the coverage in force as of the date of this application.</asp:Label>
<div class="row">
<div class="col-md-3">
<asp:Label ID="Label31" runat="server" class="fs-lbl-s" EnableViewState="False" Visible="True">Excess Carrier Name</asp:Label>
</div>
<div class="col-md-3">
<asp:Label ID="Label32" runat="server" class="fs-lbl-s" EnableViewState="False" Visible="True">Policy Effective Dates</asp:Label>
</div>
<div class="col-md-3">
<asp:Label ID="Label33" runat="server" class="fs-lbl-s" EnableViewState="False" Visible="True">Policy Limits</asp:Label>
</div>
<div class="col-md-3">
<asp:Label ID="Label34" runat="server" class="fs-lbl-s" EnableViewState="False" Visible="True">Claims-Made Form or Occurrence Form</asp:Label>
</div>
</div>
<div class="row">
<div class="col-md-3">
<asp:TextBox ID="txtExcCarierName1" runat="server" Visible="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-3">
<MaskedInput:MaskedTextBox ID="txtExcPolEffecDate1" runat="server" class="form-control mb-1 fs-txt-s" onclick="ShowDateTimePicker4();" Visible="True"></MaskedInput:MaskedTextBox>
</div>
<div class="col-md-3">
<asp:TextBox ID="txtExcPolLimits1" runat="server" Visible="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-3">
<asp:TextBox ID="txtExcClaims1" runat="server" Visible="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
</div>
<div class="row">
<div class="col-md-3">
<asp:TextBox ID="txtExcCarierName2" runat="server" Visible="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-3">
<MaskedInput:MaskedTextBox ID="txtExcPolEffecDate2" runat="server" class="form-control mb-1 fs-txt-s" onclick="ShowDateTimePicker5();" IsDate="True" Visible="True"></MaskedInput:MaskedTextBox>
</div>
<div class="col-md-3">
<asp:TextBox ID="txtExcPolLimits2" runat="server" Visible="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-3">
<asp:TextBox ID="txtExcClaims2" runat="server" Visible="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
</div>
<div class="row">
<div class="col-md-3">
<asp:TextBox ID="txtExcCarierName3" runat="server" isible="False" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-3">
<MaskedInput:MaskedTextBox ID="txtExcPolEffecDate3" runat="server" class="form-control mb-1 fs-txt-s" onclick="ShowDateTimePicker6();" IsDate="True" Visible="True"></MaskedInput:MaskedTextBox>
</div>
<div class="col-md-3">
<asp:TextBox ID="txtExcPolLimits3" runat="server" Visible="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-3">
<asp:TextBox ID="txtExcClaims3" runat="server" Visible="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
</div>
<div class="col-md-12">
<p>
<asp:Label ID="Label16" runat="server" Visible="True">4. Has any insurance company (including Lloyd's of London) ever cancelled, declines to issued,</asp:Label>
<asp:Label ID="Label23" runat="server" Visible="True">refused to renew, surcharged your premium or issued coverage with any restrictions or exclusions?</asp:Label>
<asp:Label ID="Label24" runat="server" Visible="True">If Yes, please explain fully in the below Section.</asp:Label>
</p>
<asp:RadioButtonList ID="rdoMcaInsuranceCia" class="fs-lbl-s" runat="server" RepeatDirection="Horizontal" Visible="True">
<asp:ListItem>Yes</asp:ListItem>
<asp:ListItem>No</asp:ListItem>
</asp:RadioButtonList>
<asp:Label ID="Label37" runat="server" EnableViewState="False"></asp:Label>
</div>
<asp:TextBox ID="txtInsuranceCiaDesc" runat="server" TextMode="MultiLine" Visible="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
<div class="col-md-12">
<hr>
</div>
<div class="col-md-12">
<asp:Label ID="Label9" runat="server" Visible="True">III. MEDICAL EDUCATION AND TRAINING</asp:Label>
</div>
<asp:Label ID="Label10" runat="server" Visible="True">3. Education</asp:Label>
<div class="row">
<div class="col-md-4"></div>
<div class="col-md-2">
<asp:Label ID="Label13" runat="server" class="fs-lbl-s" EnableViewState="False" Visible="True">School/Hospital</asp:Label>
</div>
<div class="col-md-2">
<asp:Label ID="Label22" runat="server" class="fs-lbl-s" EnableViewState="False" Visible="True">City/State/Country</asp:Label>
</div>
<div class="col-md-2">
<asp:Label ID="Label26" runat="server" class="fs-lbl-s" EnableViewState="False" Visible="True">From/To</asp:Label>
</div>
<div class="col-md-2">
<asp:Label ID="Label25" runat="server" class="fs-lbl-s" EnableViewState="False" Visible="True">Degree/Type</asp:Label>
</div>
</div>
<div class="row">
<div class="col-md-4">
<asp:Label ID="Label12" runat="server" class="fs-lbl-s" EnableViewState="False" Visible="True">Medical School</asp:Label>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtMedSchool" runat="server" Visible="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtMedCity" runat="server" Visible="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtMedFrom" runat="server" Visible="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtMedDegree" runat="server" Visible="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
</div>
<div class="row">
<div class="col-md-4">
<asp:Label ID="Label27" runat="server" class="fs-lbl-s" EnableViewState="False" Visible="True">Internship</asp:Label>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtIntSchool" runat="server" Visible="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtIntCity" runat="server" Visible="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtIntFrom" runat="server" Visible="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtIntDegree" runat="server" Visible="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
</div>
<div class="row">
<div class="col-md-4">
<asp:Label ID="Label30" runat="server" class="fs-lbl-s" EnableViewState="False" Visible="True">Residency</asp:Label>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtResSchool" runat="server" Visible="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtResCity" runat="server" Visible="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtResFrom" runat="server" Visible="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtResDegree" runat="server" Visible="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
</div>
<div class="row">
<div class="col-md-4">
<asp:Label ID="Label35" runat="server" class="fs-lbl-s" EnableViewState="False" Visible="True">Fellowship</asp:Label>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtFellSchool" runat="server" Visible="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtFellCity" runat="server" Visible="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtFellFrom" runat="server" Visible="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtFellDegree" runat="server" Visible="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
</div>
<div class="row">
<div class="col-md-4">
<asp:Label ID="Label36" runat="server" class="fs-lbl-s" EnableViewState="False" Visible="True">Other Training</asp:Label>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtOSchool" runat="server" Visible="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtOCity" runat="server" Visible="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtOFrom" runat="server" Visible="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
<div class="col-md-2">
<asp:TextBox ID="txtODegree" runat="server" Visible="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
</div>
</div>
<asp:HiddenField ID="hdfPrimaryLimit" runat="server" />
<asp:HiddenField ID="hdfLimit" runat="server" />
<p>
<asp:Label ID="Label11" runat="server" Visible="True">6. If you are a graduate of a non-U.S. medical school, are you certified by the Educational</asp:Label>
<asp:Label ID="Label38" runat="server" Visible="True">Commission for Foreign Medical School Graduates?</asp:Label>
</p>
<asp:RadioButtonList ID="rdoMcaCertified" runat="server" class="fs-lbl-s" RepeatDirection="Horizontal" Visible="True">
<asp:ListItem>Yes</asp:ListItem>
<asp:ListItem>No</asp:ListItem>
</asp:RadioButtonList>
<p>
<asp:Label ID="Label39" runat="server" Visible="True">7. Did you complete residency training?</asp:Label>
<asp:Label ID="Label40" runat="server" Visible="True">If "No", please explain in Remarks Section.</asp:Label>
</p>
<asp:RadioButtonList ID="rdoMcaResTraining" runat="server" class="fs-lbl-s" RepeatDirection="Horizontal" Visible="True">
<asp:ListItem>Yes</asp:ListItem>
<asp:ListItem>No</asp:ListItem>
</asp:RadioButtonList>
<div class="col-md-12">
<asp:TextBox ID="txtResidency" runat="server" TextMode="MultiLine" Visible="True" class="form-control mb-1 fs-txt-s"></asp:TextBox>
<asp:Button ID="btnNextBottom" runat="server" class="btn-h-30 btn-bg-theme2 btn-r-4" Text="Next >" OnClick="btnNextBottom_Click" Visible="True" />
</div>
<p><input id="HIState" runat="server" name="txtPrateID" size="1" style="z-index: 102; left: 912px; width: 35px; position: absolute; top: 1432px;
height: 22px" type="hidden" value="0" />
</p>
<maskedinput:maskedtextheader id="MaskedTextHeader1" runat="server"></maskedinput:maskedtextheader>
<asp:Literal ID="litPopUp" runat="server" Visible="True"></asp:Literal>
<input id="txtPrateID" runat="server" name="txtPrateID" size="1" style="z-index: 102; left: 432px; width: 35px; position: absolute; top: 1432px;
height: 22px" type="hidden" value="0" /><input id="txtPrate2ID" runat="server" name="txtPrateID" size="1" style="z-index: 102; left: 432px; width: 35px; position: absolute; top: 1468px;
height: 22px" type="hidden" value="0" />
<input id="txtPrate3ID" runat="server" name="txtPrateID" size="1" style="z-index: 102; left: 432px; width: 35px; position: absolute; top: 1500px;
height: 22px" type="hidden" value="0" />
<input id="txtPrate4ID" runat="server" name="txtPrateID" size="1" style="z-index: 102; left: 432px; width: 35px; position: absolute; top: 1528px;
height: 22px" type="hidden" value="0" />
<input id="txtPrate5ID" runat="server" name="txtPrateID" size="1" style="z-index: 102; left: 432px; width: 35px; position: absolute; top: 1560px;
height: 22px" type="hidden" value="0" />
<input id="txtPrate6ID" runat="server" name="txtPrateID" size="1" style="z-index: 102; left: 432px; width: 35px; position: absolute; top: 1592px;
height: 22px" type="hidden" value="0" />
<input id="ConfirmDialogBoxPopUp" runat="server" name="ConfirmDialogBoxPopUp" size="1" style="z-index: 102; left: 856px; width: 35px; position: absolute; top: 1432px;