www.careinsurance.com
Open in
urlscan Pro
2600:9000:2491:fe00:0:e2ff:300:93a1
Public Scan
Submitted URL: https://bit.ly/39WkAPZ
Effective URL: https://www.careinsurance.com/contact-us.html
Submission: On May 15 via api from IN — Scanned from DE
Effective URL: https://www.careinsurance.com/contact-us.html
Submission: On May 15 via api from IN — Scanned from DE
Form analysis 7 forms found in the DOM
Name: rcbForm —
<form name="rcbForm">
<div class="radio_grup">
<div class="inner">
<input type="radio" id="test1" checked="" value="cr" name="pageName">
<label for="test1">Health insurance </label>
</div>
<div class="inner">
<input type="radio" id="test2" value="tr" name="pageName">
<label for="test2">Travel insurance </label>
</div>
</div>
<div class="has_error error error_pageName "></div>
<div class="form_input borderdinput ">
<div class="floating-label">
<input autocomplete="off" type="text" name="name" data-error="Please enter valid name" class="floating-input side_btn_name" oninput="return validName(this);" placeholder=" " required="">
<label>Your Name*</label>
<p class="has_error error error_name "></p>
<span></span>
<span class="success_m_icon success_icon_span"></span>
</div>
</div>
<div class="form_input borderdinput mobilenum_input">
<div class="floating-label">
<input autocomplete="off" name="mobile" type="tel" maxlength="10" class="floating-input" placeholder=" " onkeyup="triggeronTen(this)" oninput="return isNumber(event,this,10);" onblur="return isNumber(event,this,10);">
<span class="highlight"></span>
<label>Mobile Number*</label>
<span class="country_label">+91</span>
<span class="success_icon_span">
<img class="care_spriteverified" alt="verified" title="verified" width="14" height="14" loading="lazy"
src="data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAABgAAAAYAQMAAADaua+7AAAAA1BMVEX///+nxBvIAAAAAXRSTlMAQObYZgAAAAxJREFUeNpjYKAtAAAAYAAB2E7biwAAAABJRU5ErkJggg==">
</span>
<p class="has_error error error_mobile "></p>
</div>
</div>
<div class="checkbox_grup">
<label>
<a href="javascript:void(0);" onclick="show_terms();" rel="nofollow">Terms and Conditions</a>
<input name="tnc" type="checkbox" checked="">
<span></span>
</label>
<p class="has_error error error_tnc "></p>
</div>
<!-- UTM PARAMETERS -->
<input type="hidden" name="agentId" value="20000057">
<input type="hidden" name="utm_source" value="">
<input type="hidden" name="utm_medium" value="">
<input type="hidden" name="publisher_id" value="">
<input type="hidden" name="utm_term" value="">
<input type="hidden" name="utm_content" value="">
<input type="hidden" name="utm_campaign" value="">
<div class="call_back_btn">
<a href="javascript:void(0);" id="rcb-submit" class="custum_common_btn">Request a call back</a>
</div>
</form><form>
<div class="radio_grup">
<label>New Customer <input type="radio" name="radio">
<span></span>
</label>
<label>Existing Customer <input type="radio" name="radio">
<span></span>
</label>
</div>
<div class="form_input">
<input autocomplete="off" type="text" name="yourname" placeholder="Your Name">
</div>
<p>
<input autocomplete="off" type="email" name="email" placeholder="Email">
</p>
<div class="form_input phone_num_form">
<select>
<option>+91</option>
<option>0</option>
<option>+22</option>
</select>
<input autocomplete="off" type="text" name="contactno" placeholder="0000-000-0000">
</div>
<div>
<div class="custum_common_btn">Start Chat</div>
</div>
</form>POST
<form method="post" id="ps-form" enctype="multipart/form-data">
<input autocomplete="off" type="hidden" class="" name="TouchPoint" id="TouchPoint" value="Web Portal">
<input autocomplete="off" type="hidden" class="" name="TouchPointMobile" id="TouchPointMobile" value="">
<section>
<div class="custom_container detail_form">
<p id="care_customer" class="">
<span class="care_customer">Are you a Care Insurance Customer?</span>
<label class="radiocontainer">
<input autocomplete="off" type="radio" class="radio_selection" name="radio_customer" id="care_customer_yes" checked="">
<span class="radiocheckmark"></span> Yes </label>
<label class="radiocontainer">
<input autocomplete="off" type="radio" class="radio_selection" name="radio_customer" id="care_customer_no">
<span class="radiocheckmark"></span> No </label>
</p>
<p class="group_customer_qust " id="group_customer_qust">
<span class="care_customer">Please confirm if you are corporate insurance policy holder?</span>
<label class="radiocontainer">
<input autocomplete="off" type="radio" class="radio_selection" name="group_radio" id="group_customer_yes">
<span class="radiocheckmark"></span> Yes </label>
<label class="radiocontainer">
<input autocomplete="off" type="radio" class="radio_selection" name="group_radio" id="group_customer_no" checked="">
<span class="radiocheckmark"></span> No </label>
</p>
<div class="form_flex first_row">
<div class="column policy_no_hide">
<div class="common_input">
<h4 class="input_label">Policy Number</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" name="policy_no" id="policy_no" type="tel" maxlength="8" class="floating-input policy_no" placeholder=" " value="" onpaste="return false;" ondrop="return false;" oninput="return isNumber(event,this,8);"
onblur="return isNumber(event,this,8);">
<span class="highlight"></span>
</div>
</div>
</div>
</div>
<div class="column client_id_cont">
<div class="common_input">
<h4 class="input_label">Client ID/Employee ID</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="client_id" placeholder="" value="" class="floating-input Client_Id">
</div>
</div>
</div>
</div>
<div class="column category_hide">
<div class="common_input">
<h4 class="input_label">Category <span class="color_red" id="category_mandatory">*</span></h4>
<select class="select_drop category_drop category_list" id="category" name="category">
</select>
</div>
</div>
<div class="column sub_category_hide">
<div class="common_input">
<h4 class="input_label">Sub-Category <span class="color_red" id="sub_category_mandatory">*</span></h4>
<select class="select_drop category_drop sub_category_list search_select" id="sub_category" name="sub_category" onchange="fetchHospitals(this.value);">
</select>
</div>
</div>
</div>
<div id="secondDiv">
<div class="form_flex">
<div class="column customer_name ">
<div class="common_input">
<h4 class="input_label">Name</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="contact_name" id="first_name" value="" oninput="return validName(this);" placeholder="" class="floating-input first_name" maxlength="60">
<span class="highlight"></span>
</div>
</div>
</div>
</div>
<div class="column email_wrap ">
<div class="common_input">
<h4 class="input_label">Email <span class="color_red" id="Email_mandatory">*</span></h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="email" name="email_id" id="email_id" placeholder="" value="" class="floating-input email_id" required="">
<span class="highlight"></span>
</div>
</div>
</div>
</div>
<div class="column phone_wrap ">
<div class="common_input">
<h4 class="input_label">Phone</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" name="mobile_no" id="mobile_no" type="tel" maxlength="10" class="floating-input mobile_no" placeholder=" " value="" oninput="return isNumber(event,this,10);" onblur="return isNumber(event,this,10);"
required="">
<span class="highlight"></span>
</div>
</div>
</div>
</div>
</div>
<div class="form_flex proposal_policy_div">
<div class="column">
<div class="common_input">
<h4 class="input_label">Policy Number / Proposal Number</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="policy_proposal_no" id="policy_proposal_no" placeholder="" class="floating-input">
<div id="proposal_no_error" class="error"></div>
<span class="highlight"></span>
</div>
</div>
</div>
</div>
</div>
<div class="form_flex proposal_div">
<div class="column">
<div class="common_input">
<h4 class="input_label">Proposal Number</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="tel" name="proposal_no" id="proposal_no" oninput="return isNumber(event,this,14);" minlength="8" maxlength="14" placeholder="" class="floating-input">
<div id="proposal_no_error" class="error"></div>
<span class="highlight"></span>
</div>
</div>
</div>
</div>
</div>
<div>
<div class="column subject">
<div class="common_input">
<h4 class="input_label">Subject</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="subject" id="subject" placeholder="" value="" class="floating-input subject">
</div>
</div>
</div>
</div>
</div>
<div class="hidden_cont" data-class="0">
<div class="claim_no_cont hidden">
<div class="form_flex">
<div class="column">
<div class="common_input">
<h4 class="input_label">Claim Number</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="claim_no" id="claim_no" placeholder="" value="" class="floating-input claim_no">
</div>
</div>
</div>
</div>
<div class="column" id="claim_customerid">
<div class="common_input">
<h4 class="input_label">Customer Id</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="tel" name="Customer_Id" id="Customer_Id" placeholder="" value="" class="floating-input Customer_Id" oninput="return isNumber(event,this,12);" maxlength="8" required="">
</div>
</div>
</div>
</div>
<div class="column"></div>
</div>
</div>
<div class="emply_id_cont hidden">
<div class="form_flex">
<div class="column empl_id_hide">
<div class="common_input">
<h4 class="input_label">Employee Id</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="tel" name="Employee_Id" placeholder="" value="" class="floating-input Employee_Id" oninput="return isNumber(event,this,15);">
</div>
</div>
</div>
</div>
<div class="column"></div>
<div class="column"></div>
</div>
</div>
<div class="claim_type_cont hidden">
<div class="form_flex">
<div class="column">
<div class="common_input">
<h4 class="input_label">Claim Type</h4>
<select class="select_drop claim_type_drop" name="claim_type">
<option value="">Select Claim Type</option>
<option value="Reimbursement">Reimbursement</option>
<option value="Cashless">Cashless</option>
</select>
</div>
</div>
<div class="column"></div>
<div class="column"></div>
</div>
</div>
<div class="claim_intimate hidden">
<div class="form_flex">
<div class="column">
<div class="common_input intimate_claim_type">
<h4 class="input_label">Claim Type</h4>
<select class="select_drop claim_type_drop" name="claim_type">
<option value="">Select Claim Type</option>
<option value="Reimbursement">Reimbursement</option>
<option value="Cashless">Cashless</option>
</select>
</div>
</div>
<div class="column">
<div class="common_input">
<h4 class="input_label">Patient Name</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="Patient_Name" id="Patient_Name" placeholder="" value="" class="floating-input Patient_Name">
</div>
</div>
</div>
</div>
<div class="column">
<div class="common_input">
<h4 class="input_label">Relationship with Patient</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="Relation_with_patient" id="Relation_with_patient" placeholder="" value="" class="floating-input Relation_with_patient">
</div>
</div>
</div>
</div>
</div>
<div class="form_flex">
<div class="column">
<div class="common_input">
<h4 class="input_label">Expected date of discharge</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="date_of_discharge" placeholder="" value="" class="floating-input date_of_discharge calendar_input hasDatepicker" id="dp1684126917758">
</div>
</div>
</div>
</div>
<div class="column">
<div class="common_input">
<h4 class="input_label">Date of Admission</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="Admission_date" placeholder="" value="" class="floating-input Admission_date calendar_input hasDatepicker" id="dp1684126917759">
</div>
</div>
</div>
</div>
<div class="column">
<div class="common_input">
<h4 class="input_label">Expected cost of treatment</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="tel" name="treatment_cost" id="treatment_cost" placeholder="" value="" class="floating-input treatment_cost" oninput="return isNumber(event,this,15);">
</div>
</div>
</div>
</div>
</div>
<div class="form_flex">
<div class="column">
<div class="common_input">
<h4 class="input_label">Ailment For Which Patient is Hospitalized</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="Ailment" placeholder="" value="" class="floating-input Ailment">
</div>
</div>
</div>
</div>
<div class="column">
<div class="common_input">
<h4 class="input_label">RHICL Client ID</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="RHICL_Client_ID" placeholder="" value="" class="floating-input RHICL_Client_ID">
</div>
</div>
</div>
</div>
<div class="column">
<div class="common_input">
<h4 class="input_label">Claimed Amount</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="tel" name="Claimed_Amount" placeholder="" value="" class="floating-input Claimed_Amount" oninput="return isNumber(event,this,15);">
</div>
</div>
</div>
</div>
</div>
<div class="form_flex last_row_box">
<!-- cp-24524 (by_avinash) -->
<!-- cp-24524 -->
<div class="column hidden group_claim">
<div class="common_input">
<h4 class="input_label">Group Name</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="Group_Name" placeholder="" value="" class="floating-input Group_Name">
</div>
</div>
</div>
</div>
<div class="column hidden group_claim">
<div class="common_input">
<h4 class="input_label">Employee / Insured Name</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="Employee_Insured_Name" placeholder="" value="" class="floating-input Employee_Insured_Name">
</div>
</div>
</div>
</div>
<div class="column empl_id_hide">
<div class="common_input">
<h4 class="input_label">Employee ID</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="tel" name="Employee_Id" placeholder="" value="" class="floating-input Employee_ID" oninput="return isNumber(event,this,12);">
</div>
</div>
</div>
</div>
</div>
</div>
<div class="Health_hard_copy hidden">
<div class="form_flex">
<div class="column">
<div class="common_input hard_copy_dispatch">
<h4 class="input_label">Dispatch Reports To</h4>
<select class="select_drop dispatch_to_drop" name="address_type">
<option value="">Select</option>
<option value="Permanent Address">Permanent Address</option>
<option value="Alternate Address">Alternate Address</option>
</select>
</div>
</div>
<div class="column empl_id_hide">
<div class="common_input">
<h4 class="input_label">Employee Id</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="tel" name="Employee_Id" placeholder="" value="" class="floating-input Employee_Id" oninput="return isNumber(event,this,12);">
</div>
</div>
</div>
</div>
<div class="column">
</div>
</div>
</div>
<div class="check_up_feedback hidden">
<div class="form_flex">
<div class="column">
<div class="common_input">
<h4 class="input_label">DC Name</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="DC_Name" id="DC_Name" placeholder="" value="" class="floating-input DC_Name">
</div>
</div>
</div>
</div>
<div class="column empl_id_hide">
<div class="common_input">
<h4 class="input_label">Employee Id</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="tel" name="Employee_Id" placeholder="" value="" class="floating-input Employee_Id" oninput="return isNumber(event,this,12);">
</div>
</div>
</div>
</div>
<div class="column">
</div>
</div>
</div>
<div class="cancel_reason_cont hidden">
<div class="form_flex">
<div class="column">
<div class="common_input">
<h4 class="input_label">Reason For Cancellation</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="cancel_reason" placeholder="" value="" class="floating-input cancel_reason">
</div>
</div>
</div>
</div>
<div class="column empl_id_hide">
<div class="common_input">
<h4 class="input_label">Employee Id</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="tel" name="Employee_Id" placeholder="" value="" class="floating-input Employee_Id" oninput="return isNumber(event,this,12);">
</div>
</div>
</div>
</div>
<div class="column"></div>
</div>
</div>
<div class="soft_copy_cont hidden">
<div class="form_flex">
<div class="column">
<div class="common_input soft_copy_type">
<h4 class="input_label">Type Of Soft Copy</h4>
<select class="select_drop" name="soft_copy_type">
<option value="">Select</option>
<option value="Policy Certificate">Policy Certificate</option>
<option value="Pre -Medical reports">Pre -Medical reports</option>
<option value="Renewal Letter">Renewal Letter</option>
</select>
</div>
</div>
<div class="column empl_id_hide">
<div class="common_input">
<h4 class="input_label">Employee Id</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="tel" name="Employee_Id" placeholder="" value="" class="floating-input Employee_Id" oninput="return isNumber(event,this,12);">
</div>
</div>
</div>
</div>
<div class="column"></div>
</div>
</div>
<div class="hard_copy_cont hidden">
<div class="form_flex">
<div class="column empl_id_hide">
<div class="common_input">
<h4 class="input_label">Employee Id</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="Employee_Id" placeholder="" value="" class="floating-input Employee_Id">
</div>
</div>
</div>
</div>
<div class="column reason_width">
<div class="common_input">
<h4 class="input_label">Reason</h4>
<select class="select_drop hard_copy_reason" name="hard_copy_reason">
<option value="">Select</option>
<option value="Policy documents Lost">Policy documents Lost</option>
<option value="Policy Documents Not Received">Policy Documents Not Received</option>
<option value="RTO - Returned to origin">RTO - Returned to origin</option>
<option value="Others">Others</option>
</select>
</div>
</div>
<div class="column others_width">
<div class="common_input hidden hard_copy_reason_cont">
<h4 class="input_label">Others</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="hard_copy_reason_input" placeholder="" value="" class="floating-input hard_copy_reason_input">
</div>
</div>
</div>
</div>
</div>
</div>
<div class="Duplicate_card_cont hidden">
<div class="form_flex">
<div class="column">
<div class="common_input soft_copy_type">
<h4 class="input_label">Name On Health Card</h4>
<select class="select_drop" name="name_on_health_card">
<option value="">Select</option>
<option value="Name as System">Name as System</option>
<option value="Preferred">Preferred</option>
</select>
</div>
</div>
<div class="column empl_id_hide">
<div class="common_input">
<h4 class="input_label">Employee Id</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="tel" name="Employee_Id" placeholder="" value="" class="floating-input Employee_Id" oninput="return isNumber(event,this,12);">
</div>
</div>
</div>
</div>
<div class="column"></div>
</div>
</div>
<div class="Everyday_card_cont hidden">
<div class="form_flex">
<div class="column empl_id_hide">
<div class="common_input empl_id_hide">
<h4 class="input_label">Employee Id</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="tel" name="Employee_Id" placeholder="" value="" class="floating-input Employee_Id" oninput="return isNumber(event,this,12);">
</div>
</div>
</div>
</div>
<div class="column reason_width">
<div class="common_input">
<h4 class="input_label">Reason</h4>
<select class="select_drop Everyday_card_reason" name="everyday_card_reason">
<option value="">Select</option>
<option value="Policy documents Lost">Policy documents Lost</option>
<option value="Policy Documents Not Received">Policy Documents Not Received</option>
<option value="RTO - Returned to origin">RTO - Returned to origin</option>
<option value="Others">Others</option>
</select>
</div>
</div>
<div class="column others_width">
<div class="common_input hidden Everyday_card_required">
<h4 class="input_label">Others</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="Everyday_card_reason_input" placeholder="" value="" class="floating-input Everyday_card_reason_input">
</div>
</div>
</div>
</div>
</div>
</div>
<div class="incorrect_detail_cont hidden">
<div class="form_flex">
<div class="column empl_id_hide">
<div class="common_input">
<h4 class="input_label">Employee Id</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="tel" name="Employee_Id" placeholder="" value="" class="floating-input Employee_Id" oninput="return isNumber(event,this,12);">
</div>
</div>
</div>
</div>
<div class="column reason_width">
<div class="common_input">
<h4 class="input_label">Error</h4>
<select class="select_drop Error_msg" name="Error_msg_shown_input">
<option value="">Select</option>
<option value="NCB">NCB not updated correctly / Missing</option>
<option value="NCB Super">NCB Super not updated correctly / Missing</option>
<option value="Premium Issue">Correct premium not updated</option>
<option value="Portability & First Enrollment">Portability & First Enrollment Date is wrong</option>
<option value="Rectification in Customer Details">Rectification in Customer Details</option>
<option value="Others">Others</option>
</select>
</div>
</div>
<div class="column others_width">
<div class="common_input hidden Error_msg_shown">
<h4 class="input_label">Others</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="Error_msg_shown_input_others" placeholder="" value="" class="floating-input Error_msg_shown_input">
</div>
</div>
</div>
</div>
</div>
</div>
<div class="Ped_cont hidden">
<div class="form_flex">
<div class="column client_id_hide">
<div class="common_input soft_copy_type">
<h4 class="input_label">Client Id</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="client_id" placeholder="" value="" class="floating-input Client_Id">
</div>
</div>
</div>
</div>
<div class="column empl_id_hide">
<div class="common_input">
<h4 class="input_label">Employee Id</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="tel" name="Employee_Id" placeholder="" value="" class="floating-input Employee_Id" oninput="return isNumber(event,this,12);">
</div>
</div>
</div>
</div>
<div class="column"></div>
</div>
</div>
<div class="add_insured hidden">
<div class="form_flex">
<div class="column">
<div class="common_input">
<h4 class="input_label">New Member Name </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="New_Member_Name" placeholder="" value="" class="floating-input New_Member_Name">
</div>
</div>
</div>
</div>
<div class="column">
<div class="common_input">
<h4 class="input_label">DOB of New Member </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="DOB_of_New_Member" placeholder="" value="" class="floating-input DOB_of_New_Member calendar_input hasDatepicker" id="dp1684126917760">
</div>
</div>
</div>
</div>
<div class="column empl_id_hide">
<div class="common_input">
<h4 class="input_label">Employee Id</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="tel" name="Employee_Id" placeholder="" value="" class="floating-input Employee_Id" oninput="return isNumber(event,this,12);">
</div>
</div>
</div>
</div>
</div>
</div>
<div class="address_change_cont hidden">
<div class="form_flex">
<div class="column">
<div class="common_input">
<h4 class="input_label">Address 1 </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="Address_1" placeholder="" value="" class="floating-input Address_1">
</div>
</div>
</div>
</div>
<div class="column">
<div class="common_input">
<h4 class="input_label">Address 2 </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="Address_2" placeholder="" value="" class="floating-input Address_2">
</div>
</div>
</div>
</div>
<div class="column">
<div class="common_input">
<h4 class="input_label">Pincode </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="tel" name="Pincode" placeholder="" value="" class="floating-input Pincode" oninput="return isNumber(event,this,6);" maxlength="6">
</div>
</div>
</div>
</div>
</div>
<div class="form_flex">
<div class="column">
<div class="common_input">
<h4 class="input_label">City </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="City" placeholder="" value="" class="floating-input City">
</div>
</div>
</div>
</div>
<div class="column">
<div class="common_input">
<h4 class="input_label">State </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="State" placeholder="" value="" class="floating-input State">
</div>
</div>
</div>
</div>
<div class="column empl_id_hide">
<div class="common_input">
<h4 class="input_label">Employee Id</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="tel" name="Employee_Id" placeholder="" value="" class="floating-input Employee_Id" oninput="return isNumber(event,this,12);">
</div>
</div>
</div>
</div>
</div>
</div>
<div class="dob_change hidden">
<div class="form_flex">
<div class="column">
<div class="common_input">
<h4 class="input_label">New DOB </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="New_DOB" placeholder="" value="" class="floating-input New_DOB calendar_input hasDatepicker" id="dp1684126917761">
</div>
</div>
</div>
</div>
<div class="column client_id_hide">
<div class="common_input">
<h4 class="input_label">Client Id </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="client_id" placeholder="" value="" class="floating-input Client_Id">
</div>
</div>
</div>
</div>
<div class="column empl_id_hide">
<div class="common_input">
<h4 class="input_label">Employee Id</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="tel" name="Employee_Id" placeholder="" value="" class="floating-input Employee_Id" oninput="return isNumber(event,this,12);">
</div>
</div>
</div>
</div>
</div>
</div>
<div class="email_change hidden">
<div class="form_flex">
<div class="column">
<div class="common_input">
<h4 class="input_label">New Email id </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="email" name="New_email" placeholder="" value="" class="floating-input New_email">
</div>
</div>
</div>
</div>
<div class="column empl_id_hide">
<div class="common_input">
<h4 class="input_label">Employee Id</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="tel" name="Employee_Id" placeholder="" value="" class="floating-input Employee_Id" oninput="return isNumber(event,this,12);">
</div>
</div>
</div>
</div>
<div class="column">
</div>
</div>
</div>
<div class="nominee_change hidden">
<div class="form_flex">
<div class="column">
<div class="common_input">
<h4 class="input_label">Nominee Name </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="Nominee_Name" placeholder="" value="" class="floating-input Nominee_Name">
</div>
</div>
</div>
</div>
<div class="column">
<div class="common_input">
<h4 class="input_label">Nominee Relation </h4>
<select class="select_drop Nominee_Relation" name="Nominee_Relation">
</select>
</div>
</div>
<div class="column empl_id_hide">
<div class="common_input">
<h4 class="input_label">Employee Id </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="tel" name="Employee_Id" placeholder="" value="" class="floating-input Employee_Id" oninput="return isNumber(event,this,12);">
</div>
</div>
</div>
</div>
</div>
</div>
<div class="pnone_no_change hidden">
<div class="form_flex">
<div class="column">
<div class="common_input">
<h4 class="input_label">New Mobile Number </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="tel" name="New_Mobile_Number" placeholder="" value="" class="floating-input New_Mobile_Number" oninput="return isNumber(event,this,10);" maxlength="10">
</div>
</div>
</div>
</div>
<div class="column empl_id_hide">
<div class="common_input">
<h4 class="input_label">Employee Id</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="tel" name="Employee_Id" placeholder="" value="" class="floating-input Employee_Id" oninput="return isNumber(event,this,12);">
</div>
</div>
</div>
</div>
<div class="column"></div>
</div>
</div>
<div class="travel_extension_cont hidden">
<div class="form_flex">
<div class="column">
<div class="common_input">
<h4 class="input_label">Extension Date </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="Extension_Date" placeholder="" value="" class="floating-input Extension_Date calendar_input hasDatepicker" id="dp1684126917762">
</div>
</div>
</div>
</div>
<div class="column empl_id_hide">
<div class="common_input">
<h4 class="input_label">Employee Id</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="tel" name="Employee_Id" placeholder="" value="" class="floating-input Employee_Id" oninput="return isNumber(event,this,12);">
</div>
</div>
</div>
</div>
<div class="column"></div>
</div>
</div>
<div class="rectify_pan hidden">
<div class="form_flex">
<div class="column">
<div class="common_input">
<h4 class="input_label">New PAN Number </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="New_PAN_Number" placeholder="" value="" class="floating-input New_PAN_Number" maxlength="10">
</div>
</div>
</div>
</div>
<div class="column empl_id_hide">
<div class="common_input">
<h4 class="input_label">Employee Id</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="tel" name="Employee_Id" placeholder="" value="" class="floating-input Employee_Id" oninput="return isNumber(event,this,12);">
</div>
</div>
</div>
</div>
<div class="column"></div>
</div>
</div>
<div class="rectify_passport hidden">
<div class="form_flex">
<div class="column">
<div class="common_input">
<h4 class="input_label">New Passport number </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="New_Passport_number" placeholder="" value="" class="floating-input New_Passport_number">
</div>
</div>
</div>
</div>
<div class="column client_id_hide">
<div class="common_input">
<h4 class="input_label">Client Id </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="client_id" placeholder="" value="" class="floating-input Client_Id">
</div>
</div>
</div>
</div>
<div class="column empl_id_hide">
<div class="common_input">
<h4 class="input_label">Employee Id</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="tel" name="Employee_Id" placeholder="" value="" class="floating-input Employee_Id" oninput="return isNumber(event,this,12);">
</div>
</div>
</div>
</div>
</div>
</div>
<div class="rectify_gender hidden">
<div class="form_flex">
<div class="column">
<div class="common_input">
<h4 class="input_label">New Gender </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="New_Gender" placeholder="" value="" class="floating-input New_Gender">
</div>
</div>
</div>
</div>
<div class="column client_id_hide">
<div class="common_input">
<h4 class="input_label">Client Id </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="client_id" placeholder="" value="" class="floating-input Client_Id">
</div>
</div>
</div>
</div>
<div class="column empl_id_hide">
<div class="common_input">
<h4 class="input_label">Employee Id</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="tel" name="Employee_Id" placeholder="" value="" class="floating-input Employee_Id" oninput="return isNumber(event,this,12);">
</div>
</div>
</div>
</div>
</div>
</div>
<div class="relation_cont hidden">
<div class="form_flex">
<div class="column">
<div class="common_input">
<h4 class="input_label">New Relationship </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="New_Relation" placeholder="" value="" class="floating-input New_Relation">
</div>
</div>
</div>
</div>
<div class="column client_id_hide">
<div class="common_input">
<h4 class="input_label">Client Id </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="client_id" placeholder="" value="" class="floating-input Client_Id">
</div>
</div>
</div>
</div>
<div class="column empl_id_hide">
<div class="common_input">
<h4 class="input_label">Employee Id</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="tel" name="Employee_Id" placeholder="" value="" class="floating-input Employee_Id" oninput="return isNumber(event,this,12);">
</div>
</div>
</div>
</div>
</div>
</div>
<div class="correct_insured_name hidden">
<div class="form_flex">
<div class="column First_name_width">
<div class="common_input">
<h4 class="input_label">New First name </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="New_First_name" placeholder="" value="" class="floating-input New_First_name">
</div>
</div>
</div>
</div>
<div class="column last_name_width">
<div class="common_input">
<h4 class="input_label">New Last Name </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="New_Last_Name" placeholder="" value="" class="floating-input New_Last_Name">
</div>
</div>
</div>
</div>
<div class="column client_id_hide">
<div class="common_input">
<h4 class="input_label">Client Id </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="client_id" placeholder="" value="" class="floating-input Client_Id">
</div>
</div>
</div>
</div>
</div>
<div class="form_flex">
<div class="column empl_id_hide">
<div class="common_input">
<h4 class="input_label">Employee Id</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="tel" name="Employee_Id" placeholder="" value="" class="floating-input Employee_Id" oninput="return isNumber(event,this,12);">
</div>
</div>
</div>
</div>
<div class="column"></div>
<div class="column"></div>
</div>
</div>
<div class="policy_holder_name_cont hidden">
<div class="form_flex">
<div class="column">
<div class="common_input">
<h4 class="input_label">New First name </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="New_First_name" placeholder="" value="" class="floating-input New_First_name">
</div>
</div>
</div>
</div>
<div class="column">
<div class="common_input">
<h4 class="input_label">New Last Name </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="New_Last_Name" placeholder="" value="" class="floating-input New_Last_Name">
</div>
</div>
</div>
</div>
<div class="column empl_id_hide">
<div class="common_input">
<h4 class="input_label">Employee Id</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="tel" name="Employee_Id" placeholder="" value="" class="floating-input Employee_Id" oninput="return isNumber(event,this,12);">
</div>
</div>
</div>
</div>
</div>
</div>
<div class="trip_date_change_cont hidden">
<div class="form_flex">
<div class="column">
<div class="common_input">
<h4 class="input_label">New Date </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="trip_New_Date" placeholder="" value="" class="floating-input trip_New_Date calendar_input hasDatepicker" id="dp1684126917763">
</div>
</div>
</div>
</div>
<div class="column empl_id_hide">
<div class="common_input">
<h4 class="input_label">Employee Id</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="tel" name="Employee_Id" placeholder="" value="" class="floating-input Employee_Id" oninput="return isNumber(event,this,12);">
</div>
</div>
</div>
</div>
<div class="column"></div>
</div>
</div>
<div class="rectify_course hidden">
<div class="form_flex">
<div class="column">
<div class="common_input">
<h4 class="input_label">New Course Name </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="New_Course" placeholder="" value="" class="floating-input New_Course">
</div>
</div>
</div>
</div>
<div class="column client_id_hide">
<div class="common_input">
<h4 class="input_label">Client Id </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="client_id" placeholder="" value="" class="floating-input Client_Id">
</div>
</div>
</div>
</div>
<div class="column empl_id_hide">
<div class="common_input">
<h4 class="input_label">Employee Id</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="tel" name="Employee_Id" placeholder="" value="" class="floating-input Employee_Id" oninput="return isNumber(event,this,12);">
</div>
</div>
</div>
</div>
</div>
</div>
<div class="change_sponsor_detail hidden">
<div class="form_flex">
<div class="column">
<div class="common_input">
<h4 class="input_label">New DOB </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="sponsor_dob" placeholder="" value="" class="floating-input sponsor_dob calendar_input hasDatepicker" id="dp1684126917764">
</div>
</div>
</div>
</div>
<div class="column">
<div class="common_input">
<h4 class="input_label">New Sponsor name </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="New_Sponsor_name" placeholder="" value="" class="floating-input New_Sponsor_name">
</div>
</div>
</div>
</div>
<div class="column">
<div class="common_input">
<h4 class="input_label">New Relationship </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="sponsor_New_Relation" placeholder="" value="" class="floating-input sponsor_New_Relation">
</div>
</div>
</div>
</div>
</div>
<div class="form_flex">
<div class="column client_id_hide">
<div class="common_input">
<h4 class="input_label">Client Id </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="client_id" placeholder="" value="" class="floating-input Client_Id">
</div>
</div>
</div>
</div>
<div class="column empl_id_hide">
<div class="common_input">
<h4 class="input_label">Employee Id</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="tel" name="Employee_Id" placeholder="" value="" class="floating-input Employee_Id" oninput="return isNumber(event,this,12);">
</div>
</div>
</div>
</div>
<div class="column"></div>
</div>
</div>
<div class="university_detail_change hidden">
<div class="form_flex">
<div class="column univer_name_width">
<div class="common_input">
<h4 class="input_label">New University name </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="University_name" placeholder="" value="" class="floating-input University_name">
</div>
</div>
</div>
</div>
<div class="column univer_address_width">
<div class="common_input">
<h4 class="input_label">New University address </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="University_address" placeholder="" value="" class="floating-input University_address">
</div>
</div>
</div>
</div>
<div class="column client_id_hide">
<div class="common_input">
<h4 class="input_label">Client Id </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="client_id" placeholder="" value="" class="floating-input Client_Id">
</div>
</div>
</div>
</div>
</div>
<div class="form_flex">
<div class="column empl_id_hide">
<div class="common_input">
<h4 class="input_label">Employee Id</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="tel" name="Employee_Id" placeholder="" value="" class="floating-input Employee_Id" oninput="return isNumber(event,this,12);">
</div>
</div>
</div>
</div>
<div class="column"></div>
<div class="column"></div>
</div>
</div>
<div class="MAIDEN_NAME_CHANGE hidden">
<div class="form_flex">
<div class="column">
<div class="common_input">
<h4 class="input_label">New Name </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="Maiden_New_Name" placeholder="" value="" class="floating-input Maiden_New_Name">
</div>
</div>
</div>
</div>
<div class="column empl_id_hide">
<div class="common_input">
<h4 class="input_label">Employee Id</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="tel" name="Employee_Id" placeholder="" value="" class="floating-input Employee_Id" oninput="return isNumber(event,this,12);">
</div>
</div>
</div>
</div>
<div class="column"></div>
</div>
</div>
<div class="Endorsement_Letter hidden">
<div class="form_flex">
<div class="column">
<div class="common_input">
<h4 class="input_label">Request Number</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="Request_Number" placeholder="" value="" class="floating-input Request_Number">
</div>
</div>
</div>
</div>
<div class="column">
<div class="common_input">
<h4 class="input_label">Endorsement Type </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="Endorsement_Type" placeholder="" value="" class="floating-input Endorsement_Type">
</div>
</div>
</div>
</div>
<div class="column">
<div class="common_input">
<h4 class="input_label">Date of endorsement </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="endorsement_date" placeholder="" value="" class="floating-input endorsement_date calendar_input hasDatepicker" id="dp1684126917765">
</div>
</div>
</div>
</div>
</div>
<div class="form_flex">
<div class="column empl_id_hide">
<div class="common_input">
<h4 class="input_label">Employee Id</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="tel" name="Employee_Id" placeholder="" value="" class="floating-input Employee_Id" oninput="return isNumber(event,this,12);">
</div>
</div>
</div>
</div>
<div class="column"></div>
<div class="column"></div>
</div>
</div>
<div class="new_policy_cont hidden">
<div class="form_flex">
<div class="column">
<div class="common_input">
<h4 class="input_label">Policy Type </h4>
<select class="select_drop policy_type" name="policy_type">
<option value="">Select</option>
<option value="Retail">Retail</option>
<option value="Corporate">Corporate</option>
</select>
</div>
</div>
<div class="column">
<div class="common_input hidden Corporate_detail">
<h4 class="input_label">Client Name </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="Client_Name" placeholder="" value="" class="floating-input Client_Name">
</div>
</div>
</div>
</div>
<div class="column">
<div class="common_input hidden Corporate_detail">
<h4 class="input_label">Complete Address </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="Complete_Address" placeholder="" value="" class="floating-input Complete_Address">
</div>
</div>
</div>
</div>
</div>
<div class="hidden Corporate_detail">
<div class="form_flex">
<div class="column">
<div class="common_input">
<h4 class="input_label">Number of Employees </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="tel" name="Number_of_Employees" placeholder="" value="" class="floating-input Number_of_Employees" oninput="return isNumber(event,this,16);">
</div>
</div>
</div>
</div>
<div class="column">
<div class="common_input">
<h4 class="input_label">Zone </h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" type="text" name="Zone" placeholder="" value="" class="floating-input Zone">
</div>
</div>
</div>
</div>
<div class="column"></div>
</div>
</div>
</div>
</div>
<div class="column">
<h4 class="input_label">Description <span class="color_red" id="description_mandatory">*</span></h4>
</div>
<div class="form_flex">
<div class="describe">
<div class="common_input">
<div class="floating-label">
<textarea name="description" cols="30" rows="10"></textarea>
</div>
</div>
</div>
<div class="upload documents_present" style="display:none">
<div class="policy-documents"></div>
<div class="dropzone text_center">
<input autocomplete="off" type="file" id="files" name="files" accept="image/jpg, image/jpeg, image/png, application/pdf " onchange="fileUploadPolicy(event)">
<img class="lozad" alt="attachment" title="attachment" width="50" height="50" data-src="https://www.careinsurance.com/cpproject/rhiclfrontend/assets/public/images/file_image.svg">
<p class="Browse_txt">Drag & Drop an image, or <span class="browse_btn">Browse</span></p>
<p>Support images(png, jpg, pdf). Max 5MB</p>
</div>
</div>
</div>
</div>
</div>
</section>
<section id="cust_captcha">
<div class="custom_container">
<div class="logo_input cpatcha_box">
<div class="cpatcha_img_box">
<div class="captcha_style">
<img src="" alt="captcha" title="captcha" id="captcha_id">
</div>
</div>
<div class="cpatcha_input_box" disabled="">
<input autocomplete="off" type="text" id="captchaval" name="captcha" maxlength="6">
</div>
<div class="cpatcha_refresh_box">
<img class="lozad" data-src="/cpproject/rhiclfrontend/assets/public/images/refresh.svg" alt="refresh" title="refresh">
</div>
</div>
</div>
</section>
<section id="journey_answer" style="display:none">
<div class="custom_container answer_with_url">
<div class="column">
<div class="common_input">
<h4 class="input_label">Login To Full-Fill Your Request</h4>
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" name="" id="answer_input" type="text" class="floating-input" placeholder=" " value="" readonly="">
<div class="copy_link">
<span>Copy Link </span>
<img class="lozad" alt="copy" title="copy" data-src="https://www.careinsurance.com/cpproject/rhiclfrontend/assets/public/images/copy.png">
</div>
</div>
</div>
</div>
</div>
<span class="or_option">Or</span>
<a type="button" class="cust_btn" id="answer_url" target="_blank">Click Here</a>
</div>
<div class="custom_container text_center">
<a id="answer" href="#"></a>
</div>
</section>
<section id="cus_btn">
<div class="custom_container">
<div class="text_center">
<button type="button" class="submit_btn" id="submit_btn">Submit</button>
</div>
</div>
</section>
</form><form class="form">
<div class="common_input">
<div class="form_input borderdinput">
<div class="floating-label">
<input autocomplete="off" name="otp" id="otp" type="tel" maxlength="6" class="floating-input" placeholder="Enter Otp" oninput="return isNumber(event,this,6);" onblur="return isNumber(event,this,6);">
<span class="otp-error"></span>
</div>
</div>
</div>
<button type="button" class="submit_btn" id="verify_btn">Verify OTP</button>
<div class="resend_count">
<a class="resend_otp">Resend OTP</a>
<span id="countdown"></span>
</div>
</form><form>
<div class="popup_info_img"><span><img class="lozad" alt="info_icon" title="info_icon" data-src="https://www.careinsurance.com/cpproject/rhiclfrontend/assets/public/images/information-button.png"></span></div>
<p class="pop_dtls caseID"> Request No: <span id="caseID"></span> <br> Expected closure time:<span id="TAT"></span>days </p>
<button type="" class="submit_btn" onclick="pageRefresh()">OK</button>
</form><form>
<div class="popup_info_img"><span><img class="lozad" alt="info_icon" title="info_icon" data-src="https://www.careinsurance.com/cpproject/rhiclfrontend/assets/public/images/information-button.png"></span></div>
<p class="pop_dtls">Your request no. is <span id="request_no"></span>. We will get in touch with you shortly.</p>
<button type="" class="submit_btn" onclick="pageRefresh()">OK</button>
</form>Name: sendLink —
<form name="sendLink">
<p class="head_text">Enter your Mobile number to get the link in SMS</p>
<div class="common_input">
<div class="form_input borderdinput">
<div class="floating-label">
<input class="floating-input" autocomplete="off" type="tel" name="sendLinkMob" placeholder="Phone Number" maxlength="10" oninput="return isNumber(event, this, 10);">
</div>
</div>
</div>
<p><button class="submit_btn app_link_submit">Submit</button></p>
</form>Text Content
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CLAIM NUMBER
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Select Claim Type Reimbursement Cashless
PATIENT NAME
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DATE OF ADMISSION
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AILMENT FOR WHICH PATIENT IS HOSPITALIZED
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CLAIMED AMOUNT
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Select Policy documents Lost Policy Documents Not Received RTO - Returned to
origin Others
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NAME ON HEALTH CARD
Select Name as System Preferred
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origin Others
OTHERS
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ERROR
Select NCB not updated correctly / Missing NCB Super not updated correctly /
Missing Correct premium not updated Portability & First Enrollment Date is wrong
Rectification in Customer Details Others
OTHERS
CLIENT ID
EMPLOYEE ID
NEW MEMBER NAME
DOB OF NEW MEMBER
EMPLOYEE ID
ADDRESS 1
ADDRESS 2
PINCODE
CITY
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EMPLOYEE ID
NEW DOB
CLIENT ID
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NEW EMAIL ID
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NOMINEE NAME
NOMINEE RELATION
EMPLOYEE ID
NEW MOBILE NUMBER
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EXTENSION DATE
EMPLOYEE ID
NEW PAN NUMBER
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CLIENT ID
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CLIENT ID
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CLIENT ID
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CLIENT ID
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NEW DATE
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CLIENT ID
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NEW SPONSOR NAME
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