engageconsulting.uhcsrinternational.com
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65.210.198.206
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URL:
https://engageconsulting.uhcsrinternational.com/
Submission: On May 20 via api from US — Scanned from DE
Submission: On May 20 via api from US — Scanned from DE
Form analysis 2 forms found in the DOM
Name: conLogin — POST /Student/SignIn
<form action="/Student/SignIn" method="post" name="conLogin" id="conLogin" class="unauth-header-section" style="">
<fieldset class="border-0">
<legend class="sr-only">Student login form</legend><label class="sr-only" id="email-label">Student Email</label><input type="email" aria-label="student email" aria-labeledby="email-label" class="email" name="Email" id="email"
placeholder="Email address:">
<br>
<label class="sr-only" id="password-label">Student Password</label><input type="password" aria-label="student password" aria-labeledby="password-label" class="password" name="Password" id="password" placeholder="Password:">
<table role="presentation">
<tbody>
<tr>
<td class="middle left">
<a href="/Student/ResetPassword" class="forgot-password-link" data-underline="1">Forgot Password?<span class="underline"></span></a>
</td>
<td class="middle right">
<button class="btn login-btn cta-btn">Sign In</button>
<input type="hidden" name="action" value="students">
<input type="hidden" name="action_mode" value="student_login">
</td>
</tr>
</tbody>
</table>
</fieldset>
</form><form>
<div class="text-red mb-3 text-2xl" style="display: none;"> <!----></div>
<div class="text-red mb-3 text-2xl" style="display: none;"></div>
<div class="text-red mb-3 text-2xl" style="display: none;"> No plans are available for this school. Contact <a href="/page/customer-service">customer service</a> for more detail. </div>
<div class="text-red mb-3 text-2xl" style="display: none;"> Please <a href="/dashboard">log in to your account</a> to see if you are eligible for this coverage. </div>
<div class="md:flex md:mb-8 md:-mx-4">
<div class="px-4 md:w-1/3 mb-8 md:mb-0"><label class="block font-normal">Student Date of Birth <span class="text-lg text-grey-darker">(MM/DD/YYYY)</span> <i class="text-danger">*</i> <span class="text-red" style="display: none;">
</span></label>
<div class="relative"><input type="text" placeholder="Enter Date of Birth" class="tw-input tw-input-text"> <svg aria-hidden="true" focusable="false" data-prefix="far" data-icon="calendar-alt" role="img" xmlns="http://www.w3.org/2000/svg"
viewBox="0 0 448 512" class="absolute pin-r pin-middle mr-4 pointer-events-none text-primary svg-inline--fa fa-calendar-alt fa-w-14 fa-lg">
<path fill="currentColor"
d="M148 288h-40c-6.6 0-12-5.4-12-12v-40c0-6.6 5.4-12 12-12h40c6.6 0 12 5.4 12 12v40c0 6.6-5.4 12-12 12zm108-12v-40c0-6.6-5.4-12-12-12h-40c-6.6 0-12 5.4-12 12v40c0 6.6 5.4 12 12 12h40c6.6 0 12-5.4 12-12zm96 0v-40c0-6.6-5.4-12-12-12h-40c-6.6 0-12 5.4-12 12v40c0 6.6 5.4 12 12 12h40c6.6 0 12-5.4 12-12zm-96 96v-40c0-6.6-5.4-12-12-12h-40c-6.6 0-12 5.4-12 12v40c0 6.6 5.4 12 12 12h40c6.6 0 12-5.4 12-12zm-96 0v-40c0-6.6-5.4-12-12-12h-40c-6.6 0-12 5.4-12 12v40c0 6.6 5.4 12 12 12h40c6.6 0 12-5.4 12-12zm192 0v-40c0-6.6-5.4-12-12-12h-40c-6.6 0-12 5.4-12 12v40c0 6.6 5.4 12 12 12h40c6.6 0 12-5.4 12-12zm96-260v352c0 26.5-21.5 48-48 48H48c-26.5 0-48-21.5-48-48V112c0-26.5 21.5-48 48-48h48V12c0-6.6 5.4-12 12-12h40c6.6 0 12 5.4 12 12v52h128V12c0-6.6 5.4-12 12-12h40c6.6 0 12 5.4 12 12v52h48c26.5 0 48 21.5 48 48zm-48 346V160H48v298c0 3.3 2.7 6 6 6h340c3.3 0 6-2.7 6-6z"
class=""></path>
</svg></div>
</div>
<div class="px-4 md:w-1/3 mb-8 md:mb-0"><label for="school" class="block font-normal"> School/Organization <i class="text-danger">*</i> <span class="text-red" style="display: none;">
</span></label>
<div class="relative p-0 text-primary">
<div><input type="text" placeholder="Enter School/Organization" maxlength="200" title="" class="tw-input tw-input-text text-overflow-ellipsis pr-10"> <svg aria-hidden="true" focusable="false" data-prefix="fas" data-icon="caret-down"
role="img" xmlns="http://www.w3.org/2000/svg" viewBox="0 0 320 512" class="text-primary h-6 absolute pin-r pin-middle mr-4 pointer-events-none svg-inline--fa fa-caret-down fa-w-10 fa-lg">
<path fill="currentColor" d="M31.3 192h257.3c17.8 0 26.7 21.5 14.1 34.1L174.1 354.8c-7.8 7.8-20.5 7.8-28.3 0L17.2 226.1C4.6 213.5 13.5 192 31.3 192z" class=""></path>
</svg></div>
<div class="w-full"><span style="display: none;">
<div class="popper solid static">
<div class="p-6 bg-primary">
<div class="mb-4 font-bold text-white">Or find by:</div>
<div class="mb-4">
<div class="relative p-0 text-primary">
<div unselectable="on" title="Location" tabindex="0" class="flex p-4 content-center justify-between leading-input bg-white text-overflow-ellipsis whitespace-no-wrap text-grey-dark border border-primary hover:cursor-pointer"><span
class="mr-2 text-overflow-ellipsis">Location</span> <svg aria-hidden="true" focusable="false" data-prefix="fas" data-icon="caret-down" role="img" xmlns="http://www.w3.org/2000/svg" viewBox="0 0 320 512"
class="text-primary h-6 pointer-events-none svg-inline--fa fa-caret-down fa-w-10 fa-lg">
<path fill="currentColor" d="M31.3 192h257.3c17.8 0 26.7 21.5 14.1 34.1L174.1 354.8c-7.8 7.8-20.5 7.8-28.3 0L17.2 226.1C4.6 213.5 13.5 192 31.3 192z" class=""></path>
</svg></div>
<div class="absolute w-full border pt-0 bg-white border-primary border-t-0 font-bold z-10" style="display: none;">
<hr class="border mx-3 my-0 border-primary">
<div class="max-h-dropdown overflow-y-auto"><!---->
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option"><!---->
<div class="px-4 py-3">National</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">Alabama</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">Alaska</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">Arizona</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">Arkansas</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">California</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">Colorado</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">Connecticut</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">Delaware</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">District of Columbia</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">Florida</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">Georgia</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">Hawaii</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">Idaho</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">Illinois</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">Indiana</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">Iowa</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">Kansas</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">Kentucky</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">Louisiana</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">Maine</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">Maryland</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">Massachusetts</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">Michigan</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">Minnesota</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">Mississippi</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">Missouri</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">Montana</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">Nebraska</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">Nevada</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">New Hampshire</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">New Jersey</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">New Mexico</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">New York</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">North Carolina</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">North Dakota</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">Ohio</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">Oklahoma</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">Oregon</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">Pennsylvania</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">Rhode Island</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">South Carolina</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">South Dakota</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">Tennessee</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">Texas</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">Utah</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">Vermont</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">Virginia</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">Washington</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">West Virginia</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">Wisconsin</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">Wyoming</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="mb-4">
<div class="relative p-0 text-primary">
<div unselectable="on" title="School/Organization" class="flex p-4 content-center justify-between leading-input bg-white text-overflow-ellipsis whitespace-no-wrap text-grey-dark border border-primary opacity-50"><span
class="mr-2 text-overflow-ellipsis">School/Organization</span> <svg aria-hidden="true" focusable="false" data-prefix="fas" data-icon="caret-down" role="img" xmlns="http://www.w3.org/2000/svg" viewBox="0 0 320 512"
class="text-primary h-6 pointer-events-none svg-inline--fa fa-caret-down fa-w-10 fa-lg">
<path fill="currentColor" d="M31.3 192h257.3c17.8 0 26.7 21.5 14.1 34.1L174.1 354.8c-7.8 7.8-20.5 7.8-28.3 0L17.2 226.1C4.6 213.5 13.5 192 31.3 192z" class=""></path>
</svg></div>
<div class="absolute w-full border pt-0 bg-white border-primary border-t-0 font-bold z-10" style="display: none;">
<hr class="border mx-3 my-0 border-primary">
<div class="max-h-dropdown overflow-y-auto"><!----> </div>
</div>
</div>
</div>
</div>
</div>
</span>
<div class="absolute min-w-full border pt-0 bg-white border-primary border-t-0 font-bold z-10" style="display: none;">
<hr class="border my-0 border-primary">
<div class="max-h-dropdown overflow-y-auto">
<div></div>
<div>
<div class="font-bold text-primary px-4 py-3 center"> Start by typing a name </div>
</div> <!---->
</div>
</div>
</div>
</div>
</div>
<div class="px-4 md:w-1/3 mb-8 md:mb-0"><label for="studentCategory" class="block font-normal"> Student Category <i class="text-danger">*</i> <span class="text-red" style="display: none;">
</span></label>
<div class="relative p-0 text-primary">
<div unselectable="on" title="Choose option" tabindex="0" class="flex p-4 content-center justify-between leading-input bg-white text-overflow-ellipsis whitespace-no-wrap text-grey-dark border border-primary hover:cursor-pointer"><span
class="mr-2 text-overflow-ellipsis">Choose option</span> <svg aria-hidden="true" focusable="false" data-prefix="fas" data-icon="caret-down" role="img" xmlns="http://www.w3.org/2000/svg" viewBox="0 0 320 512"
class="text-primary h-6 pointer-events-none svg-inline--fa fa-caret-down fa-w-10 fa-lg">
<path fill="currentColor" d="M31.3 192h257.3c17.8 0 26.7 21.5 14.1 34.1L174.1 354.8c-7.8 7.8-20.5 7.8-28.3 0L17.2 226.1C4.6 213.5 13.5 192 31.3 192z" class=""></path>
</svg></div>
<div class="absolute w-full border pt-0 bg-white border-primary border-t-0 font-bold z-10" style="display: none;">
<hr class="border mx-3 my-0 border-primary">
<div class="max-h-dropdown overflow-y-auto"><!---->
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option"><!---->
<div class="px-4 py-3">F1 International Students</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">J1 International Students</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">English Language Program</div>
</div>
</div>
<div tabindex="-1">
<div class="hover:bg-primary hover:text-white hover:cursor-pointer select-list-option">
<hr class="border mx-3 my-0">
<div class="px-4 py-3">Optional Practical Training</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="flex flex-col md:flex-row md:mb-8 md:-mx-4 justify-between">
<div class="order-3 md:order-none px-4 md:w-1/3 mb-8 md:mb-0"><label class="font-bold text-secondary block font-normal"> </label>
<div class="relative">
<div><button class="p-4 bg-primary w-full font-bold text-white flex flex-row justify-between"><span>Add Coverage (Spouse / Child)</span> <svg aria-hidden="true" focusable="false" data-prefix="fas" data-icon="caret-down" role="img"
xmlns="http://www.w3.org/2000/svg" viewBox="0 0 320 512" class="text-white h-6 pointer-events-none svg-inline--fa fa-caret-down fa-w-10 fa-lg">
<path fill="currentColor" d="M31.3 192h257.3c17.8 0 26.7 21.5 14.1 34.1L174.1 354.8c-7.8 7.8-20.5 7.8-28.3 0L17.2 226.1C4.6 213.5 13.5 192 31.3 192z" class=""></path>
</svg></button>
<div class="absolute w-full border pt-0 bg-white border-primary border-t-0 z-10" style="display: none;">
<div class="max-h-dropdown overflow-y-auto">
<div class="mb-0 flex mr-3 sm:mr-12 justify-between w-full py-4 px-6 items-center"><span class="mr-3">Spouse</span>
<div class="flex flex-col justify-between mt-px"><span tabindex="0" class="border rounded-full border-grey flex cursor-pointer w-32 sm:w-16 justify-start items-center"><span
class="rounded-full border w-14 h-14 sm:w-7 sm:h-7 border-grey shadow-inner bg-white shadow"></span></span></div>
</div>
<hr class="border-2 border-grey-lighter my-0 px-6">
<div class="mb-0 flex mr-3 sm:mr-12 justify-between w-full py-4 px-6 items-center"><span class="mr-3">Children</span>
<div class="flex items-center"><button class="rounded-full bg-primary w-14 h-14 sm:w-8 sm:h-8 flex justify-center mr-3"><svg aria-hidden="true" focusable="false" data-prefix="fas" data-icon="minus" role="img"
xmlns="http://www.w3.org/2000/svg" viewBox="0 0 448 512" class="text-white self-center svg-inline--fa fa-minus fa-w-14">
<path fill="currentColor" d="M416 208H32c-17.67 0-32 14.33-32 32v32c0 17.67 14.33 32 32 32h384c17.67 0 32-14.33 32-32v-32c0-17.67-14.33-32-32-32z" class=""></path>
</svg></button> <span class="mr-3 font-bold">0</span> <button class="rounded-full bg-primary w-14 h-14 sm:w-8 sm:h-8 flex justify-center mr-3"><svg aria-hidden="true" focusable="false" data-prefix="fas" data-icon="plus" role="img"
xmlns="http://www.w3.org/2000/svg" viewBox="0 0 448 512" class="text-white self-center svg-inline--fa fa-plus fa-w-14">
<path fill="currentColor"
d="M416 208H272V64c0-17.67-14.33-32-32-32h-32c-17.67 0-32 14.33-32 32v144H32c-17.67 0-32 14.33-32 32v32c0 17.67 14.33 32 32 32h144v144c0 17.67 14.33 32 32 32h32c17.67 0 32-14.33 32-32V304h144c17.67 0 32-14.33 32-32v-32c0-17.67-14.33-32-32-32z"
class=""></path>
</svg></button></div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="md:w-2/3 opacity-50">
<div class="md:flex">
<div class="md:w-1/2 px-4 mb-8 md:mb-0"><label class="block font-normal"> Choose Start Date <i class="text-danger">*</i> <span class="text-red" style="display: none;">
</span></label>
<div class="relative"><input type="text" placeholder="Choose start date" disabled="disabled" aria-disabled="true" class="tw-input tw-input-text"> <svg aria-hidden="true" focusable="false" data-prefix="far" data-icon="calendar-alt"
role="img" xmlns="http://www.w3.org/2000/svg" viewBox="0 0 448 512" class="absolute pin-r pin-middle mr-4 pointer-events-none text-primary svg-inline--fa fa-calendar-alt fa-w-14 fa-lg">
<path fill="currentColor"
d="M148 288h-40c-6.6 0-12-5.4-12-12v-40c0-6.6 5.4-12 12-12h40c6.6 0 12 5.4 12 12v40c0 6.6-5.4 12-12 12zm108-12v-40c0-6.6-5.4-12-12-12h-40c-6.6 0-12 5.4-12 12v40c0 6.6 5.4 12 12 12h40c6.6 0 12-5.4 12-12zm96 0v-40c0-6.6-5.4-12-12-12h-40c-6.6 0-12 5.4-12 12v40c0 6.6 5.4 12 12 12h40c6.6 0 12-5.4 12-12zm-96 96v-40c0-6.6-5.4-12-12-12h-40c-6.6 0-12 5.4-12 12v40c0 6.6 5.4 12 12 12h40c6.6 0 12-5.4 12-12zm-96 0v-40c0-6.6-5.4-12-12-12h-40c-6.6 0-12 5.4-12 12v40c0 6.6 5.4 12 12 12h40c6.6 0 12-5.4 12-12zm192 0v-40c0-6.6-5.4-12-12-12h-40c-6.6 0-12 5.4-12 12v40c0 6.6 5.4 12 12 12h40c6.6 0 12-5.4 12-12zm96-260v352c0 26.5-21.5 48-48 48H48c-26.5 0-48-21.5-48-48V112c0-26.5 21.5-48 48-48h48V12c0-6.6 5.4-12 12-12h40c6.6 0 12 5.4 12 12v52h128V12c0-6.6 5.4-12 12-12h40c6.6 0 12 5.4 12 12v52h48c26.5 0 48 21.5 48 48zm-48 346V160H48v298c0 3.3 2.7 6 6 6h340c3.3 0 6-2.7 6-6z"
class=""></path>
</svg></div>
</div>
<div class="md:w-1/2 px-4 mb-8 md:mb-0"><label class="block font-normal"> Choose End Date <i class="text-danger">*</i> <span class="text-red" style="display: none;">
</span></label>
<div class="relative"><input type="text" placeholder="Choose end date" disabled="disabled" aria-disabled="true" class="tw-input tw-input-text"> <svg aria-hidden="true" focusable="false" data-prefix="far" data-icon="calendar-alt" role="img"
xmlns="http://www.w3.org/2000/svg" viewBox="0 0 448 512" class="absolute pin-r pin-middle mr-4 pointer-events-none text-primary svg-inline--fa fa-calendar-alt fa-w-14 fa-lg">
<path fill="currentColor"
d="M148 288h-40c-6.6 0-12-5.4-12-12v-40c0-6.6 5.4-12 12-12h40c6.6 0 12 5.4 12 12v40c0 6.6-5.4 12-12 12zm108-12v-40c0-6.6-5.4-12-12-12h-40c-6.6 0-12 5.4-12 12v40c0 6.6 5.4 12 12 12h40c6.6 0 12-5.4 12-12zm96 0v-40c0-6.6-5.4-12-12-12h-40c-6.6 0-12 5.4-12 12v40c0 6.6 5.4 12 12 12h40c6.6 0 12-5.4 12-12zm-96 96v-40c0-6.6-5.4-12-12-12h-40c-6.6 0-12 5.4-12 12v40c0 6.6 5.4 12 12 12h40c6.6 0 12-5.4 12-12zm-96 0v-40c0-6.6-5.4-12-12-12h-40c-6.6 0-12 5.4-12 12v40c0 6.6 5.4 12 12 12h40c6.6 0 12-5.4 12-12zm192 0v-40c0-6.6-5.4-12-12-12h-40c-6.6 0-12 5.4-12 12v40c0 6.6 5.4 12 12 12h40c6.6 0 12-5.4 12-12zm96-260v352c0 26.5-21.5 48-48 48H48c-26.5 0-48-21.5-48-48V112c0-26.5 21.5-48 48-48h48V12c0-6.6 5.4-12 12-12h40c6.6 0 12 5.4 12 12v52h128V12c0-6.6 5.4-12 12-12h40c6.6 0 12 5.4 12 12v52h48c26.5 0 48 21.5 48 48zm-48 346V160H48v298c0 3.3 2.7 6 6 6h340c3.3 0 6-2.7 6-6z"
class=""></path>
</svg></div>
</div>
</div>
</div>
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