| Current File : /home/digitaw/Ycof/.history/sante_20230608160852.php |
<?php
include 'menu.php';
?>
<link rel="stylesheet" href="css/voyag.css">
<body>
<!-- Page Header End -->
<div class="container-fluid page-header5 mb-5 wow fadeIn" data-wow-delay="0.1s">
<div class="container">
</div>
</div>
<!--Service Start -->
<div class="container-xxl service py-5" id="distance">
<div class="container">
<div class="text-center mx-auto wow fadeInUp" data-wow-delay="0.1s" style="max-width: 600px;">
<h1 class="display-5 mb-2">Description</h1>
<p class="mb-5">L’assurance Maladie est un dispositif permettant aux assurés de se prémunir contre les risques Maladie, Accidents et Maternité.</p>
</div>
<div class="wrapper shadow p-4">
<div class="header">
<ul>
<li class="active form_1_progessbar">
<div>
<p>1</p>
</div>
</li>
<li class="form_2_progessbar">
<div>
<p>2</p>
</div>
</li>
<li class="form_3_progessbar">
<div>
<p>3</p>
</div>
</li>
</ul>
</div>
<form id="sante">
<div class="form_wrap">
<div class="form_1 data_info">
<h3>Bénéficiaires</h3>
<select class="form-select" name="beneficiaire" aria-label="Default select example" id="benificiaire" onchange="validateBenificiaire()">
<option selected></option>
<option value="solo">Solo</option>
<option value="Famille">Famille</option>
<option value="Entreprise">Enteprise</option>
</select>
<p id="benificiaire-error"></p>
<div class="input_wrap">
<label for="company">Nom : </label>
<input type="text" name="nom" id="nom" class="form-control" oninput="validateNom()">
<p id="nom-error"></p>
</div>
<div class="input_wrap">
<label for="experience">Prénom : </label>
<input type="text" name="prenom" id="prenom" class="form-control" oninput="validatePrenom()">
<p id="prenom-error"></p>
</div>
<div class="input_wrap">
<label for="designation">Email : </label>
<input type="email" name="mail" id="email" class="form-control" oninput="validateEmail()">
<p id="email-error"></p>
</div>
<div class="input_wrap">
<label for="dat_retour">Telephone : </label>
<input type="tel" name="phone" id="telephone" class="form-control" oninput="validatePhone()">
<p id="telephone-error"></p>
</div>
</div>
<div class="form_2 data_info" style="display: none;">
<h3>Détail de l'assurance santé</h3>
<p>Veuillez remplir ce formulaire</p>
<div class="form_container">
<div class="input_wrap">
<label for="dest">Taux de couverture:</label>
<div class="form-check">
<input class="form-check-input" value="70%" type="radio" name="taux" id="flexRadioDefault1">
<label class="form-check-label" for="flexRadioDefault1">
Taux 70%
</label>
</div>
<div class="form-check">
<input class="form-check-input" value="80%" type="radio" name="taux" id="flexRadioDefault2" checked>
<label class="form-check-label" for="flexRadioDefault2">
Taux 80%
</label>
</div>
<div class="form-check">
<input class="form-check-input" value="90%" type="radio" name="taux" id="flexRadioDefault3" checked>
<label class="form-check-label" for="flexRadioDefault2">
Taux 90%
</label>
</div>
</div>
<div class="input_wrap">
<label for="nub_pass">Téritorialité:</label>
</div>
<div>
<select class="form-select" name="localite" aria-label="Default select example" id="localite" onchange="validateLocalite()">
<option >Choisir votre localité</option>
<option value="Senegal">Sénégal</option>
<option value="Afrique entière">Afrique entière</option>
<option value="Sénégal + Union Européenne">Sénégal + Union Européenne</option>
<option value="Monde entière">Monde entière </option>
</select>
<p id="localite-error"></p>
</div>
</div>
</div>
<div class="form_3 data_info" style="display: none;">
<h3>Récapitulatif Devis</h3>
<div class="form_container">
<div class="input_wrap">
<label for="company">Bénéficiaire : <b id="beneficiaire-recap"></b></label>
</div>
<div class="input_wrap">
<label for="experience">Taux : <b id="taux-recap""></b></label>
</div>
<div class=" input_wrap">
<label for="designation">Localité : <b id="localite-recap"></b></label>
</div>
</div>
</div>
</div>
<div class="btns_wrap">
<div class="common_btns form_1_btns">
<button type="button" class="btn_next">Next <span class="icon"><ion-icon name="arrow-forward-sharp"></ion-icon></span></button>
</div>
<div class="common_btns form_2_btns" style="display: none;">
<button type="button" class="btn_back"><span class="icon"><ion-icon name="arrow-back-sharp"></ion-icon></span>Back</button>
<button type="button" class="btn_next" onclick="loadData()">Next <span class="icon"><ion-icon name="arrow-forward-sharp"></ion-icon></span></button>
</div>
<div class="common_btns form_3_btns" style="display: none;">
<button type="button" class="btn_back"><span class="icon"><ion-icon name="arrow-back-sharp"></ion-icon></span>Back</button>
<button type="submit" class="btn_done">Envoyer</button>
</div>
</div>
</form>
</div>
</div>
</div>
</div>
</div>
<!-- Footer Start -->
<?php
include 'footer.php';
?>
<script src="js/sante.js"></script>
</body>
</html>