plac-micro-common 1.3.20 → 1.3.22
This diff represents the content of publicly available package versions that have been released to one of the supported registries. The information contained in this diff is provided for informational purposes only and reflects changes between package versions as they appear in their respective public registries.
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@@ -2,570 +2,730 @@
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Object.defineProperty(exports, "__esModule", { value: true });
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exports.SIO_FORM_EN_TEMPLATE = void 0;
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exports.SIO_FORM_EN_TEMPLATE = `
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<!doctype html>
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<html lang="en">
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<head>
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<meta charset="UTF-8" />
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<meta name="viewport" content="width=device-width, initial-scale=1.0" />
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<title>SIO Insurance Application Form</title>
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<link rel="preconnect" href="https://fonts.googleapis.com">
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<link rel="preconnect" href="https://fonts.gstatic.com" crossorigin>
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<style>
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body {
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font-family: Arial, Helvetica, system-ui, sans-serif;
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font-size: 12px;
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line-height: 1.4;
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margin: 1rem;
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/* Reduced from 2rem */
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background: #fff;
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color: #000;
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}
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.space {
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width: 8px;
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}
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/* margin */
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.ml-4 {margin-left: 1rem; }
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.ml-8 {margin-left: 2rem; }
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.mr-4 {margin-right: 1rem; }
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.mr-8 {margin-right: 2rem; }
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.mt-4 {margin-top: 1rem; }
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.mt-8 {margin-top: 2rem; }
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.mb-4 {margin-bottom: 1rem; }
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.mb-8 {margin-bottom: 2rem; }
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/* alignment */
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.align-left { justify-content: flex-start !important; text-align: left; padding-left: 16px; }
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.align-right { justify-content: flex-end !important; text-align: right; padding-right: 16px; }
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.align-center { justify-content: center !important; text-align: center; }
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.space-height {
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height: 60px;
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align-items: center;
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}
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.signature-space {
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height: 100px;
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margin-top: 10px;
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}
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/* === Page header === */
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.page-header {
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margin-bottom: 0.5rem;
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page-break-inside: avoid;
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}
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.header-container {
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display: flex;
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flex-direction: column;
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align-items: center;
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}
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.title-logo {
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width: 125px;
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height: auto;
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}
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.title {
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font-weight: 700;
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font-size: 18px;
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line-height: 1;
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}
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.title-container {
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text-align: center;
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font-weight: 700;
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font-size: 16px;
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line-height: 1.4;
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margin: 0;
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}
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/* === Card Header === */
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.card-header {
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background-color: #0d6efd;
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color: white;
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text-align: center;
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padding: 0.1rem 0;
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border-radius: 6px 6px 0 0;
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font-size: 1rem;
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font-weight: bold;
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margin-bottom: 0.5rem;
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/* Reduced */
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-webkit-print-color-adjust: exact;
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print-color-adjust: exact;
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}
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/* === Form Text === */
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.form-container {
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display: flex;
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flex-wrap: wrap;
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margin: 0;
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padding: 0;
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gap: 0.5rem;
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}
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.form-item {
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display: flex;
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align-items: flex-start;
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flex-wrap: wrap;
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width: 100%;
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}
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.label,
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.question-label {
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word-wrap: break-word;
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white-space: normal;
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font-weight: 500;
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color: #444;
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}
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/* Underline for blanks */
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.underline {
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border-bottom: 1px dashed #000;
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flex: 1;
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min-width: 60px;
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min-height: 1em;
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display: inline-flex;
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align-items: center;
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justify-content: center;
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text-align: center;
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word-break: break-word;
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white-space: normal;
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-webkit-box-decoration-break: clone;
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box-decoration-break: clone;
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align-self: flex-end;
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color: #000;
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}
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/* size variants */
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.underline.xs { flex: none; width: 30px; min-width: unset; }
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.underline.sm { flex: none; width: 80px; min-width: unset; }
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.underline.md { flex: none; width: 180px; min-width: unset; }
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.underline.lg { flex: 2; }
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.underline.with-unit {
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flex: 1;
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min-width: 0;
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display: block;
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word-break: break-word;
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white-space: normal;
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border-bottom: none;
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line-height: 1.6em;
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text-align: left;
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padding-left: 4px;
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}
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.with-unit .value {
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display: inline;
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text-decoration: underline;
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text-decoration-style: dashed;
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text-decoration-color: #000;
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text-underline-offset: 3px;
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-webkit-box-decoration-break: clone;
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box-decoration-break: clone;
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vertical-align: baseline;
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}
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.unit {
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display: inline;
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white-space: nowrap;
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margin-left: 4px;
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text-decoration: none;
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}
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/* Checkbox labels */
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.checkbox-label {
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display: inline-flex;
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align-items: center;
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gap: 0.5rem;
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position: relative;
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cursor: pointer;
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padding-left: 0.2rem;
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user-select: none;
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}
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.checkbox-label::before {
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content: "";
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display: inline-flex;
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align-items: center;
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justify-content: center;
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width: 20px;
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height: 20px;
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border: 2px solid #555;
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border-radius: 3px;
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background-color: #fff;
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box-sizing: border-box;
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flex-shrink: 0;
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table {
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body {
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@page {
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size: A4 portrait;
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margin: 15mm 15mm 20mm 10mm;
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/* increased right margin slightly for better spacing */
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@bottom-right {
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content: "ទំព័រ " counter(page) " នៃ " counter(pages);
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font-size: 11px;
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/* Increment page counter */
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body {
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counter-increment: page;
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}
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.page-header,
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.title-container,
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table {
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page-break-inside: avoid;
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}
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.card-header {
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-webkit-print-color-adjust: exact;
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print-color-adjust: exact;
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}
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}
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</style>
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</head>
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<body>
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<div class="page-header mb-8">
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<img src="data:image/png;base64,<%= logo_base64 %>" alt="Logo" class="title-logo" />
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<div class="title-container">
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<h1 class="title">LIFE ASSURANCE APPLICATION FORM</h1>
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<h1 class="title">
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SIMPLIFY FORM FOR CHOKCHEY FINANCE PLC (SIO)
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</h1>
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</div>
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</div>
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<div class="cb-item">
|
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|
-
<div class="cb-box <%= applicant_info?.gender === 'M' ? 'checked' : '' %>"></div>
|
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250
|
-
<span>ប្រុស</span>
|
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305
|
+
|
|
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|
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<div class="form-container">
|
|
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|
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<div class="form-item">
|
|
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|
+
<span class="label">Branch Name and Code:</span>
|
|
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|
+
<span class="underline">
|
|
310
|
+
<%= branch_staff_app_info.branch_name %> / <%= branch_staff_app_info.branch_code %>
|
|
311
|
+
</span>
|
|
312
|
+
<span class="label">Advisor's Name and Code:</span>
|
|
313
|
+
<span class="underline">
|
|
314
|
+
<%= branch_staff_app_info.advisor_name %> / <%= branch_staff_app_info.advisor_code %>
|
|
315
|
+
</span>
|
|
251
316
|
</div>
|
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|
-
<div class="
|
|
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|
-
<
|
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|
-
<span
|
|
317
|
+
<div class="form-item">
|
|
318
|
+
<span class="label">Bank staff's name and code:</span>
|
|
319
|
+
<span class="underline">
|
|
320
|
+
<%= branch_staff_app_info.bank_staff_name %> / <%= branch_staff_app_info.bank_staff_code %>
|
|
321
|
+
</span>
|
|
322
|
+
<span class="label">Application Number:</span>
|
|
323
|
+
<span class="underline">
|
|
324
|
+
<%= branch_staff_app_info.application_no %>
|
|
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|
+
</span>
|
|
255
326
|
</div>
|
|
256
327
|
</div>
|
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|
-
|
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|
-
|
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|
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|
-
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|
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<div class="
|
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|
-
<div class="
|
|
263
|
-
<
|
|
264
|
-
<span
|
|
328
|
+
|
|
329
|
+
<!-- Section 1 -->
|
|
330
|
+
<div class="card-header mt-4">INFORMATION ABOUT THE APPLICANT</div>
|
|
331
|
+
|
|
332
|
+
<div class="form-container">
|
|
333
|
+
<div class="form-item">
|
|
334
|
+
<span class="label">Full Name as shown in identity documents: in KH Language:</span>
|
|
335
|
+
<span class="underline"><%= applicant_info.full_name_kh %></span>
|
|
336
|
+
<span class="label">EN Language:</span>
|
|
337
|
+
<span class="underline"><%= applicant_info.full_name %></span>
|
|
265
338
|
</div>
|
|
266
|
-
|
|
267
|
-
|
|
268
|
-
<span
|
|
339
|
+
|
|
340
|
+
<div class="form-item">
|
|
341
|
+
<span class="label">Gender:</span>
|
|
342
|
+
<label class="checkbox-label <%= applicant_info.gender === 'M' ? 'checked' : '' %>">M</label>
|
|
343
|
+
<label class="checkbox-label <%= applicant_info.gender === 'F' ? 'checked' : '' %>">F</label>
|
|
344
|
+
|
|
345
|
+
<div class="ml-8"></div>
|
|
346
|
+
|
|
347
|
+
<div>
|
|
348
|
+
<span class="label">Marital Status:</span>
|
|
349
|
+
<label class="checkbox-label <%= applicant_info.marital_status === 'single' ? 'checked' : '' %>">
|
|
350
|
+
Single
|
|
351
|
+
</label>
|
|
352
|
+
<label class="checkbox-label <%= applicant_info.marital_status === 'married' ? 'checked' : '' %>">
|
|
353
|
+
Married
|
|
354
|
+
</label>
|
|
355
|
+
<label class="checkbox-label <%= applicant_info.marital_status === 'divorced' ? 'checked' : '' %>">
|
|
356
|
+
Divorced
|
|
357
|
+
</label>
|
|
358
|
+
<label class="checkbox-label <%= applicant_info.marital_status === 'widowed' ? 'checked' : '' %>">
|
|
359
|
+
Widowed
|
|
360
|
+
</label>
|
|
361
|
+
</div>
|
|
269
362
|
</div>
|
|
270
|
-
|
|
271
|
-
|
|
272
|
-
<span
|
|
363
|
+
|
|
364
|
+
<div class="form-item">
|
|
365
|
+
<span class="label">Job Title and Nature of Work:</span>
|
|
366
|
+
<span class="underline align-left"><%= applicant_info.occupation %></span>
|
|
273
367
|
</div>
|
|
274
|
-
|
|
275
|
-
|
|
276
|
-
<span
|
|
368
|
+
|
|
369
|
+
<div class="form-item">
|
|
370
|
+
<span class="label">Identity documents:</span>
|
|
371
|
+
<label class="checkbox-label <%= applicant_info.identity_type === 'nid' ? 'checked' : '' %>">
|
|
372
|
+
National ID Card
|
|
373
|
+
</label>
|
|
374
|
+
<label class="checkbox-label <%= applicant_info.identity_type === 'passport' ? 'checked' : '' %>">
|
|
375
|
+
Passport
|
|
376
|
+
</label>
|
|
377
|
+
<label class="checkbox-label <%= applicant_info.identity_type === 'birth' ? 'checked' : '' %>">
|
|
378
|
+
Birth Certificate
|
|
379
|
+
</label>
|
|
380
|
+
<label class="checkbox-label <%= applicant_info.identity_type === 'other' ? 'checked' : '' %>">
|
|
381
|
+
Others :
|
|
382
|
+
</label>
|
|
383
|
+
|
|
384
|
+
|
|
385
|
+
<!-- other field stays separate since it has extra input -->
|
|
386
|
+
<label class="underline"><%= applicant_info.identity_other_description %></label>
|
|
277
387
|
</div>
|
|
388
|
+
|
|
389
|
+
<div class="form-item">
|
|
390
|
+
<span class="label">Identity #</span>
|
|
391
|
+
<span class="underline"><%= applicant_info.identity_no %></span>
|
|
392
|
+
<span class="label">DOB:</span>
|
|
393
|
+
<span class="underline"><%= applicant_info.date_of_birth %></span>
|
|
394
|
+
<span class="label">Age:</span>
|
|
395
|
+
<span class="underline xs"><%= applicant_info.age %></span>
|
|
396
|
+
<span class="label">Nationality:</span>
|
|
397
|
+
<span class="underline"><%= applicant_info.nationality %></span>
|
|
398
|
+
<span class="label">Phone #:</span>
|
|
399
|
+
<span class="underline"><%= applicant_info.phone_number %></span>
|
|
400
|
+
</div>
|
|
401
|
+
|
|
402
|
+
<div class="form-item">
|
|
403
|
+
<span class="label">Current Address:</span>
|
|
404
|
+
<span class="underline align-left"><%= applicant_info.current_address %></span>
|
|
405
|
+
</div>
|
|
406
|
+
|
|
407
|
+
|
|
278
408
|
</div>
|
|
279
|
-
|
|
280
|
-
|
|
281
|
-
|
|
282
|
-
|
|
283
|
-
|
|
284
|
-
|
|
285
|
-
<div class="cb-group">
|
|
286
|
-
<div class="cb-item">
|
|
287
|
-
<div class="cb-box <%= applicant_info?.identity_type === 'nid' ? 'checked' : '' %>"></div>
|
|
288
|
-
<span>អត្តសញ្ញាណបណ្ណ</span>
|
|
409
|
+
|
|
410
|
+
|
|
411
|
+
|
|
412
|
+
<div class="form-container">
|
|
413
|
+
<div class="form-item mt-4">
|
|
414
|
+
<span class="label">Declaration on FATCA implementation</span>
|
|
289
415
|
</div>
|
|
290
|
-
<div class="
|
|
291
|
-
<
|
|
292
|
-
|
|
416
|
+
<div class="form-item">
|
|
417
|
+
<span class="label">
|
|
418
|
+
The Policyholder is not USA citizen / USA resident for tax purpose or holding Green Card.
|
|
419
|
+
</span>
|
|
293
420
|
</div>
|
|
294
|
-
<div class="
|
|
295
|
-
<
|
|
296
|
-
<
|
|
421
|
+
<div class="form-item">
|
|
422
|
+
<label class="checkbox-label <%= fatca_info.is_fatca === false ? 'checked' : '' %>">No</label>
|
|
423
|
+
<label class="checkbox-label <%= fatca_info.is_fatca === true ? 'checked' : '' %>">Yes</label>
|
|
424
|
+
<span class="label">US TIN #:</span>
|
|
425
|
+
<span class="underline"><%= fatca_info.us_tin_no %></span>
|
|
426
|
+
<span class="label">FATCA Exemption Code (If have):</span>
|
|
427
|
+
<span class="underline"><%= fatca_info.fatca_exempt_code %></span>
|
|
297
428
|
</div>
|
|
298
|
-
<div class="
|
|
299
|
-
<
|
|
300
|
-
|
|
429
|
+
<div class="form-item">
|
|
430
|
+
<span class="label">
|
|
431
|
+
If any of the certifications I have provided are incorrect, I will submit a new document within 30 days, and I certify that I am not subject to U.S. withholding tax.
|
|
432
|
+
</span>
|
|
301
433
|
</div>
|
|
302
434
|
</div>
|
|
303
|
-
|
|
304
|
-
|
|
305
|
-
|
|
306
|
-
|
|
307
|
-
<
|
|
308
|
-
|
|
309
|
-
|
|
310
|
-
|
|
311
|
-
|
|
312
|
-
|
|
313
|
-
|
|
314
|
-
|
|
315
|
-
|
|
316
|
-
|
|
317
|
-
|
|
318
|
-
|
|
319
|
-
|
|
320
|
-
|
|
321
|
-
|
|
322
|
-
|
|
323
|
-
|
|
324
|
-
|
|
325
|
-
|
|
326
|
-
|
|
327
|
-
|
|
328
|
-
|
|
329
|
-
|
|
330
|
-
|
|
331
|
-
|
|
332
|
-
|
|
333
|
-
|
|
334
|
-
|
|
335
|
-
|
|
336
|
-
<
|
|
337
|
-
|
|
338
|
-
|
|
339
|
-
|
|
340
|
-
|
|
341
|
-
|
|
435
|
+
|
|
436
|
+
|
|
437
|
+
|
|
438
|
+
<!-- Section 2 -->
|
|
439
|
+
<div class="card-header mt-4">INFORMATION ABOUT THE PRODUCT
|
|
440
|
+
</div>
|
|
441
|
+
<div class="table-container">
|
|
442
|
+
<table>
|
|
443
|
+
<thead>
|
|
444
|
+
<tr>
|
|
445
|
+
<th><div class="cell">NAME OF PRODUCT AND TERMS</div></th>
|
|
446
|
+
<th><div class="cell">SUM ASSURED (USD)</div></th>
|
|
447
|
+
<th><div class="cell">MODE OF PAYMENT</div></th>
|
|
448
|
+
<th>
|
|
449
|
+
<div class="cell">PREMIUM (USD)</div>
|
|
450
|
+
</th>
|
|
451
|
+
</tr>
|
|
452
|
+
</thead>
|
|
453
|
+
<tbody>
|
|
454
|
+
<% product_payment_info?.products?.forEach(function(product) { %>
|
|
455
|
+
<tr>
|
|
456
|
+
<td><div class="cell"><%= product.name %> <%= product.term %></div></td>
|
|
457
|
+
<td><div class="cell"><%= product.sum_assured %></div></td>
|
|
458
|
+
<td><div class="cell"><%= product.payment_mode %></div></td>
|
|
459
|
+
<td><div class="cell"><%= product.premium %></div></td>
|
|
460
|
+
</tr>
|
|
461
|
+
<% }) %>
|
|
462
|
+
</tbody>
|
|
463
|
+
</table>
|
|
464
|
+
</div>
|
|
465
|
+
<div class="form-container">
|
|
466
|
+
<div class="form-item">
|
|
467
|
+
<span class="question-label">Method of payment:</span>
|
|
468
|
+
<label class="checkbox-label <%= product_payment_info.payment_method === 'transfer_to_plac' ? 'checked' : '' %>">
|
|
469
|
+
Credit to Phillip Life Account
|
|
470
|
+
</label>
|
|
471
|
+
<label class="checkbox-label <%= product_payment_info.payment_method === 'other' ? 'checked' : '' %>">
|
|
472
|
+
Through Phillip Life's partner
|
|
473
|
+
</label>
|
|
342
474
|
</div>
|
|
343
475
|
</div>
|
|
344
|
-
|
|
345
|
-
|
|
346
|
-
<
|
|
347
|
-
<
|
|
348
|
-
|
|
349
|
-
|
|
350
|
-
<div class="health-q" style="font-size:7.8pt; color:#333;">
|
|
351
|
-
ប្រសិនបើការបញ្ចាក់អះអាងណាមួយមិនត្រឹមត្រូវ ខ្ញុំនឹងប្រគល់ជូននូវឯកសារថ្មីក្នុងរយះពេល ៣០ថ្ងៃហើយអះអាងថាខ្ញុំមិនជាប់ពន្ធកាត់ទុករបស់សហរដ្ឋអាមេរិកទេ។
|
|
352
|
-
</div>
|
|
353
|
-
|
|
354
|
-
<div class="section-header">ព័ត៌មានអំពីផលិតផល</div>
|
|
355
|
-
|
|
356
|
-
<table>
|
|
357
|
-
<thead>
|
|
358
|
-
<tr>
|
|
359
|
-
<th>ឈ្មោះផលិតផល និងរយះពេលធានា</th>
|
|
360
|
-
<th>ទឹកប្រាក់ត្រូវធានា<br/>(ដុល្លារអាមេរិក)</th>
|
|
361
|
-
<th>របៀបបង់បុព្វលាភ</th>
|
|
362
|
-
<th>បុព្វលាភធានារ៉ាប់រង់<br/>(ដុល្លារអាមេរិក)</th>
|
|
363
|
-
</tr>
|
|
364
|
-
</thead>
|
|
365
|
-
<tbody>
|
|
366
|
-
<% if (product_payment_info?.products && product_payment_info.products.length > 0) { %>
|
|
367
|
-
<% product_payment_info.products.forEach((p) => { %>
|
|
476
|
+
|
|
477
|
+
<!-- Section 3 -->
|
|
478
|
+
<div class="card-header mt-4">INFORMATION ABOUT THE BENEFICIARY(IES)</div>
|
|
479
|
+
<div class="table-container">
|
|
480
|
+
<table>
|
|
481
|
+
<thead>
|
|
368
482
|
<tr>
|
|
369
|
-
<
|
|
370
|
-
<
|
|
371
|
-
<
|
|
372
|
-
<
|
|
483
|
+
<th><div class="cell">FULL NAME OF BENEFICIARY</div></th>
|
|
484
|
+
<th><div class="cell">AGE</div></th>
|
|
485
|
+
<th><div class="cell">RELATIONSHIP</div></th>
|
|
486
|
+
<th><div class="cell">IDENTITY NUMBER</div></th>
|
|
487
|
+
<th><div class="cell">% OF SHARE</div></th>
|
|
373
488
|
</tr>
|
|
374
|
-
|
|
375
|
-
|
|
376
|
-
|
|
377
|
-
<td class="td-empty"></td>
|
|
378
|
-
<td class="td-empty"></td>
|
|
379
|
-
<td class="td-empty"></td>
|
|
380
|
-
<td class="td-empty"></td>
|
|
381
|
-
</tr>
|
|
382
|
-
<tr>
|
|
383
|
-
<td class="td-empty"></td>
|
|
384
|
-
<td class="td-empty"></td>
|
|
385
|
-
<td class="td-empty"></td>
|
|
386
|
-
<td class="td-empty"></td>
|
|
387
|
-
</tr>
|
|
388
|
-
<% } %>
|
|
389
|
-
</tbody>
|
|
390
|
-
</table>
|
|
391
|
-
|
|
392
|
-
<div class="field-row">
|
|
393
|
-
<span class="label">វិធីសាស្រ្ដបង់បុព្វលាភធានារ៉ាប់រង់:</span>
|
|
394
|
-
<div class="cb-group">
|
|
395
|
-
<div class="cb-item">
|
|
396
|
-
<div class="cb-box <%= product_payment_info?.payment_method === 'transfer' ? 'checked' : '' %>"></div>
|
|
397
|
-
<span>ការផ្ទេរប្រាក់</span>
|
|
398
|
-
</div>
|
|
399
|
-
<div class="cb-item">
|
|
400
|
-
<div class="cb-box <%= product_payment_info?.payment_method === 'cash' ? 'checked' : '' %>"></div>
|
|
401
|
-
<span>សាច់ប្រាក់</span>
|
|
402
|
-
</div>
|
|
403
|
-
</div>
|
|
404
|
-
</div>
|
|
405
|
-
|
|
406
|
-
<div class="section-header">ព័ត៌មានអំពីអ្នកទទួលផល</div>
|
|
407
|
-
|
|
408
|
-
<table>
|
|
409
|
-
<thead>
|
|
410
|
-
<tr>
|
|
411
|
-
<th>ឈ្មោះពេញរបស់អ្នកទទួលផល</th>
|
|
412
|
-
<th>អាយុ</th>
|
|
413
|
-
<th>ទំនាក់ទំនង</th>
|
|
414
|
-
<th>លេខអតិថិជន/ឯកសារ</th>
|
|
415
|
-
<th>% នៃការបែងចែក</th>
|
|
416
|
-
</tr>
|
|
417
|
-
</thead>
|
|
418
|
-
<tbody>
|
|
419
|
-
<% if (beneficiary_info && beneficiary_info.length > 0) { %>
|
|
420
|
-
<% beneficiary_info.forEach((b) => { %>
|
|
489
|
+
</thead>
|
|
490
|
+
<tbody>
|
|
491
|
+
<% beneficiary_info?.forEach(function(beneficiary) { %>
|
|
421
492
|
<tr>
|
|
422
|
-
<td><%=
|
|
423
|
-
<td><%=
|
|
424
|
-
<td><%=
|
|
425
|
-
<td><%=
|
|
426
|
-
<td><%=
|
|
493
|
+
<td><div class="cell"><%= beneficiary.full_name %></div></td>
|
|
494
|
+
<td><div class="cell"><%= beneficiary.age %></div></td>
|
|
495
|
+
<td><div class="cell"><%= beneficiary.relationship %></div></td>
|
|
496
|
+
<td><div class="cell"><%= beneficiary.id_number %></div></td>
|
|
497
|
+
<td><div class="cell"><%= beneficiary.percentage %></div></td>
|
|
427
498
|
</tr>
|
|
428
|
-
|
|
429
|
-
|
|
430
|
-
|
|
431
|
-
|
|
432
|
-
|
|
433
|
-
|
|
434
|
-
|
|
435
|
-
|
|
436
|
-
|
|
437
|
-
|
|
438
|
-
|
|
439
|
-
|
|
440
|
-
|
|
441
|
-
|
|
442
|
-
|
|
443
|
-
|
|
444
|
-
|
|
445
|
-
|
|
446
|
-
<td class="td-empty"></td>
|
|
447
|
-
<td class="td-empty"></td>
|
|
448
|
-
<td class="td-empty"></td>
|
|
449
|
-
<td class="td-empty"></td>
|
|
450
|
-
</tr>
|
|
451
|
-
<% } %>
|
|
452
|
-
</tbody>
|
|
453
|
-
</table>
|
|
454
|
-
|
|
455
|
-
<div class="note">
|
|
456
|
-
<span>កណត់សម្គាល់៖ ប្រសិនបើភាគរយមិនត្រូវបានបញ្ជាក់ចំនួនទឹកប្រាក់នឹងត្រូវបែងចែកស្មើៗគ្នា</span>
|
|
457
|
-
<span>% សរុបស្មើរ ១០០%</span>
|
|
458
|
-
</div>
|
|
459
|
-
|
|
460
|
-
<div class="section-header">ព័ត៌មានពាក់ព័ន្ទនឹងសុខភាពរបស់ អ្នកស្នើសុំបណ្ណសន្យារ៉ាប់រង់</div>
|
|
461
|
-
|
|
462
|
-
<div class="health-q">
|
|
463
|
-
<span class="q-text">1) កម្ពស់:</span>
|
|
464
|
-
<span class="underline xs"><%= health_info?.height ?? '' %></span> ស.ម
|
|
465
|
-
<span class="q-text" style="margin-left:8px;">ទម្ងន់:</span>
|
|
466
|
-
<span class="underline xs"><%= health_info?.weight ?? '' %></span> គ.ក
|
|
467
|
-
<span class="q-text" style="margin-left:8px;">តើលោកអ្នកពិសារបារីដែរឬទេ?:</span>
|
|
468
|
-
<div class="cb-group" style="display:inline-flex; margin-left:4px;">
|
|
469
|
-
<div class="cb-item">
|
|
470
|
-
<div class="cb-box <%= health_info?.is_smoke === false ? 'checked' : '' %>"></div>
|
|
471
|
-
<span>មិនមាន</span>
|
|
472
|
-
</div>
|
|
473
|
-
<div class="cb-item">
|
|
474
|
-
<div class="cb-box <%= health_info?.is_smoke === true ? 'checked' : '' %>"></div>
|
|
475
|
-
<span>មាន</span>
|
|
476
|
-
</div>
|
|
499
|
+
<% }) %>
|
|
500
|
+
<tr>
|
|
501
|
+
<td colspan="4">
|
|
502
|
+
<div class="cell">
|
|
503
|
+
Note:
|
|
504
|
+
If the percentage is not specified the amount will be shared equally
|
|
505
|
+
</div>
|
|
506
|
+
</td>
|
|
507
|
+
<td><div class="cell">% Total 100 %</div></td>
|
|
508
|
+
</tr>
|
|
509
|
+
</tbody>
|
|
510
|
+
</table>
|
|
511
|
+
</div>
|
|
512
|
+
|
|
513
|
+
<!-- Section 4 -->
|
|
514
|
+
<div class="page-break"></div>
|
|
515
|
+
<div class="card-header">
|
|
516
|
+
HEALTH RELATED QUESTIONS
|
|
477
517
|
</div>
|
|
478
|
-
|
|
479
|
-
|
|
480
|
-
|
|
481
|
-
|
|
482
|
-
|
|
483
|
-
|
|
484
|
-
|
|
485
|
-
<div class="
|
|
486
|
-
<span
|
|
518
|
+
|
|
519
|
+
<!-- Question 1 -->
|
|
520
|
+
<div class="form-container mt-8">
|
|
521
|
+
<div class="form-item">
|
|
522
|
+
<span class="label">1) Height:</span>
|
|
523
|
+
<span class="underline sm"><%= health_info.height %></span>
|
|
524
|
+
<span class="label">cm</span>
|
|
525
|
+
<div class="space"></div>
|
|
526
|
+
<span class="label">Weight:</span>
|
|
527
|
+
<span class="underline sm"><%= health_info.weight %></span>
|
|
528
|
+
<span class="label">Kg</span>
|
|
529
|
+
<div class="space"></div>
|
|
530
|
+
<span class="question-label">A) Do you smoke?</span>
|
|
531
|
+
<label class="checkbox-label <%= health_info.is_smoke === false ? 'checked' : '' %>">
|
|
532
|
+
No
|
|
533
|
+
</label>
|
|
534
|
+
<label class="checkbox-label <%= health_info.is_smoke === true ? 'checked' : '' %>">
|
|
535
|
+
Yes
|
|
536
|
+
</label>
|
|
487
537
|
</div>
|
|
488
|
-
|
|
489
|
-
|
|
490
|
-
<span
|
|
538
|
+
|
|
539
|
+
<div class="form-item">
|
|
540
|
+
<span class="label">How many</span>
|
|
541
|
+
<% if (health_info.smoke_detail) { %>
|
|
542
|
+
<span class="underline with-unit">
|
|
543
|
+
<span class="value"><%= health_info.smoke_detail %></span>
|
|
544
|
+
<span class="unit">per day</span>
|
|
545
|
+
</span>
|
|
546
|
+
<% } else { %>
|
|
547
|
+
<span class="underline"></span>
|
|
548
|
+
<% } %>
|
|
491
549
|
</div>
|
|
492
550
|
</div>
|
|
493
|
-
|
|
494
|
-
|
|
495
|
-
|
|
496
|
-
|
|
497
|
-
|
|
498
|
-
|
|
499
|
-
|
|
500
|
-
|
|
501
|
-
<
|
|
551
|
+
|
|
552
|
+
<!-- Question 2 -->
|
|
553
|
+
<div class="form-container mt-8">
|
|
554
|
+
<div class="form-item">
|
|
555
|
+
<span class="question-label">2) Do you drink alcohol?</span>
|
|
556
|
+
<label class="checkbox-label <%= health_info.is_drink_alcohol === false ? 'checked' : '' %>">
|
|
557
|
+
No
|
|
558
|
+
</label>
|
|
559
|
+
<label class="checkbox-label <%= health_info.is_drink_alcohol === true ? 'checked' : '' %>">
|
|
560
|
+
Yes
|
|
561
|
+
</label>
|
|
502
562
|
</div>
|
|
503
|
-
<div class="
|
|
504
|
-
<
|
|
505
|
-
|
|
563
|
+
<div class="form-item">
|
|
564
|
+
<span class="label">Please specify amount of drink per week</span>
|
|
565
|
+
<% if (health_info.drink_alcohol_detail) { %>
|
|
566
|
+
<span class="underline with-unit">
|
|
567
|
+
<span class="value"><%= health_info.drink_alcohol_detail %></span>
|
|
568
|
+
</span>
|
|
569
|
+
<% } else { %>
|
|
570
|
+
<span class="underline"></span>
|
|
571
|
+
<% } %>
|
|
506
572
|
</div>
|
|
507
573
|
</div>
|
|
508
574
|
|
|
509
|
-
|
|
510
|
-
|
|
511
|
-
|
|
512
|
-
|
|
513
|
-
|
|
514
|
-
|
|
515
|
-
|
|
516
|
-
|
|
517
|
-
|
|
518
|
-
|
|
519
|
-
|
|
520
|
-
|
|
521
|
-
<div class="cb-box <%= health_info?.is_diagnosed === false ? 'checked' : '' %>"></div>
|
|
522
|
-
<span>មិនមាន</span>
|
|
575
|
+
<!-- Question 3 -->
|
|
576
|
+
<div class="form-container mt-8">
|
|
577
|
+
<span class="question-label">
|
|
578
|
+
3) In the past 2 years, have you ever been hospitalized, undergone any surgical operation, or had abnormal results such as: Blood test, Urine test, X-ray, ECG, Ultrasound, Scan, Biopsy or any other test results.
|
|
579
|
+
</span>
|
|
580
|
+
<div class="form-item">
|
|
581
|
+
<label class="checkbox-label <%= health_info.is_hospitalized === false ? 'checked' : '' %>">
|
|
582
|
+
No
|
|
583
|
+
</label>
|
|
584
|
+
<label class="checkbox-label <%= health_info.is_hospitalized === true ? 'checked' : '' %>">
|
|
585
|
+
Yes
|
|
586
|
+
</label>
|
|
523
587
|
</div>
|
|
524
|
-
|
|
525
|
-
|
|
526
|
-
<span
|
|
588
|
+
|
|
589
|
+
<div class="form-item">
|
|
590
|
+
<span class="label">provided more details:</span>
|
|
591
|
+
<% if (health_info.hospitalized_detail) { %>
|
|
592
|
+
<span class="underline with-unit">
|
|
593
|
+
<span class="value"><%= health_info.hospitalized_detail %></span>
|
|
594
|
+
</span>
|
|
595
|
+
<% } else { %>
|
|
596
|
+
<span class="underline"></span>
|
|
597
|
+
<% } %>
|
|
527
598
|
</div>
|
|
528
599
|
</div>
|
|
529
600
|
|
|
530
|
-
|
|
531
|
-
|
|
532
|
-
<
|
|
533
|
-
|
|
534
|
-
|
|
535
|
-
|
|
536
|
-
|
|
537
|
-
|
|
538
|
-
|
|
539
|
-
|
|
540
|
-
|
|
541
|
-
|
|
542
|
-
|
|
543
|
-
<div class="sig-row">
|
|
544
|
-
<div class="sig-block">
|
|
545
|
-
<div>ហត្ថលេខា ឬស្នាមមេដៃរបស់អ្នកស្នើសុំធានារ៉ាប់រង</div>
|
|
546
|
-
<div class="sig-line"></div>
|
|
547
|
-
<div class="field-row">
|
|
548
|
-
<span class="label">ឈ្មោះ</span>
|
|
549
|
-
<span class="underline full"><%= signature_info?.applicant_name ?? '' %></span>
|
|
601
|
+
<!-- Question 4 -->
|
|
602
|
+
<div class="form-container mt-8">
|
|
603
|
+
<span class="question-label">
|
|
604
|
+
4) Have you ever been diagnosed with, consulted a medical practitioner or been given treatment for any of the following conditions: Hypertension, Diabetes, Heart diseases, Chest pain, Lung diseases, Liver disease, Renal diseases, Cancer, Stroke, AIDS, Mental illness, Disability or Deformity, Drug or Alcohol Abuse or Any other diseases are not mentioned above.
|
|
605
|
+
</span>
|
|
606
|
+
<div class="form-item">
|
|
607
|
+
<label class="checkbox-label <%= health_info.is_diagnosed === false ? 'checked' : '' %>">
|
|
608
|
+
No
|
|
609
|
+
</label>
|
|
610
|
+
<label class="checkbox-label <%= health_info.is_diagnosed === true ? 'checked' : '' %>">
|
|
611
|
+
Yes
|
|
612
|
+
</label>
|
|
613
|
+
|
|
550
614
|
</div>
|
|
551
|
-
<div class="
|
|
552
|
-
<span class="label"
|
|
553
|
-
|
|
615
|
+
<div class="form-item">
|
|
616
|
+
<span class="label">if yes, please provided more details:</span>
|
|
617
|
+
<% if (health_info.diagnosed_detail) { %>
|
|
618
|
+
<span class="underline with-unit">
|
|
619
|
+
<span class="value"><%= health_info.diagnosed_detail %></span>
|
|
620
|
+
</span>
|
|
621
|
+
<% } else { %>
|
|
622
|
+
<span class="underline"></span>
|
|
623
|
+
<% } %>
|
|
554
624
|
</div>
|
|
555
625
|
</div>
|
|
556
|
-
|
|
557
|
-
|
|
558
|
-
|
|
559
|
-
|
|
560
|
-
|
|
561
|
-
<span class="
|
|
626
|
+
|
|
627
|
+
<!-- Section 5 -->
|
|
628
|
+
<div class="card-header mt-4">DECLARATION BY THE APPLICANT</div>
|
|
629
|
+
<div class="form-container">
|
|
630
|
+
<div class="form-item">
|
|
631
|
+
<span class="label">
|
|
632
|
+
1) I authorize and consent the Company to use all of my information provided in my application form for legal purposes such as marketing, market survey and customer service by company, affiliate, or business partner without my prior consent or notification. The Company shall not allow to disclose any information of any other purpose not related to the above-mentioned purpose without prior consent in writing.
|
|
633
|
+
</span>
|
|
562
634
|
</div>
|
|
563
|
-
<div class="
|
|
564
|
-
<span class="label"
|
|
565
|
-
|
|
635
|
+
<div class="form-item">
|
|
636
|
+
<span class="label">
|
|
637
|
+
2) I hereby confirm that I have read and understood all the information in this document. I declare that all the information provided in this application form is complete, accurate, and true.
|
|
638
|
+
</span>
|
|
566
639
|
</div>
|
|
567
640
|
</div>
|
|
568
|
-
|
|
569
|
-
|
|
641
|
+
<div class="table-container mt-4">
|
|
642
|
+
<table>
|
|
643
|
+
<thead>
|
|
644
|
+
<tr>
|
|
645
|
+
<th style="width: 50%">
|
|
646
|
+
<div class="cell">
|
|
647
|
+
Signature or Thumb print of the Applicant
|
|
648
|
+
</div>
|
|
649
|
+
<div class="signature-space"></div>
|
|
650
|
+
</th>
|
|
651
|
+
<th style="width: 50%">
|
|
652
|
+
<div class="cell">Signature or Thumb print of the witness</div>
|
|
653
|
+
<div class="signature-space"></div>
|
|
654
|
+
</th>
|
|
655
|
+
</tr>
|
|
656
|
+
</thead>
|
|
657
|
+
<tbody>
|
|
658
|
+
<tr>
|
|
659
|
+
<td>
|
|
660
|
+
<div class="form-container space-height">
|
|
661
|
+
<div class="form-item">
|
|
662
|
+
<div class="space"></div>
|
|
663
|
+
<span class="label">Name</span>
|
|
664
|
+
<% if (signature_info.applicant_name) { %>
|
|
665
|
+
<span class="underline with-unit">
|
|
666
|
+
<span class="value"><%= signature_info.applicant_name %></span>
|
|
667
|
+
</span>
|
|
668
|
+
<% } else { %>
|
|
669
|
+
<span class="underline"></span>
|
|
670
|
+
<% } %>
|
|
671
|
+
<div class="space"></div>
|
|
672
|
+
</div>
|
|
673
|
+
</div>
|
|
674
|
+
</td>
|
|
675
|
+
<td>
|
|
676
|
+
<div class="form-container space-height">
|
|
677
|
+
<div class="form-item">
|
|
678
|
+
<div class="space"></div>
|
|
679
|
+
<span class="label">Name</span>
|
|
680
|
+
<% if (signature_info.witness_name) { %>
|
|
681
|
+
<span class="underline with-unit">
|
|
682
|
+
<span class="value"><%= signature_info.witness_name %></span>
|
|
683
|
+
</span>
|
|
684
|
+
<% } else { %>
|
|
685
|
+
<span class="underline"></span>
|
|
686
|
+
<% } %>
|
|
687
|
+
<div class="space"></div>
|
|
688
|
+
</div>
|
|
689
|
+
</div>
|
|
690
|
+
</td>
|
|
691
|
+
</tr>
|
|
692
|
+
<tr>
|
|
693
|
+
<td>
|
|
694
|
+
<div class="form-container space-height">
|
|
695
|
+
<div class="form-item">
|
|
696
|
+
<div class="space"></div>
|
|
697
|
+
<span class="label">Date</span>
|
|
698
|
+
<% if (signature_info.applicant_signature_date) { %>
|
|
699
|
+
<span class="underline with-unit" >
|
|
700
|
+
<span class="value"><%= signature_info.applicant_signature_date %></span>
|
|
701
|
+
</span>
|
|
702
|
+
<% } else { %>
|
|
703
|
+
<span class="underline"></span>
|
|
704
|
+
<% } %>
|
|
705
|
+
<div class="space"></div>
|
|
706
|
+
</div>
|
|
707
|
+
</div>
|
|
708
|
+
</td>
|
|
709
|
+
<td>
|
|
710
|
+
<div class="form-container space-height">
|
|
711
|
+
<div class="form-item">
|
|
712
|
+
<div class="space"></div>
|
|
713
|
+
<span class="label">Date</span>
|
|
714
|
+
<% if (signature_info.witness_signature_date) { %>
|
|
715
|
+
<span class="underline with-unit">
|
|
716
|
+
<span class="value"><%= signature_info.witness_signature_date %></span>
|
|
717
|
+
</span>
|
|
718
|
+
<% } else { %>
|
|
719
|
+
<span class="underline"></span>
|
|
720
|
+
<% } %>
|
|
721
|
+
<div class="space"></div>
|
|
722
|
+
</div>
|
|
723
|
+
</div>
|
|
724
|
+
</td>
|
|
725
|
+
</tr>
|
|
726
|
+
</tbody>
|
|
727
|
+
</table>
|
|
728
|
+
</div>
|
|
729
|
+
</body>
|
|
570
730
|
</html>
|
|
571
731
|
`;
|