plac-micro-common 1.3.93 → 1.3.95

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Files changed (4) hide show
  1. package/dist/libs/pdf-form/templates/uw-form.template.d.ts +1 -1
  2. package/dist/libs/pdf-form/templates/uw-form.template.js +1 -1
  3. package/dist/types/pdf-form/sio-form.type.d.ts +6 -0
  4. package/package.json +1 -1
package/dist/libs/pdf-form/templates/uw-form.template.d.ts CHANGED
@@ -1 +1 @@
1
- export declare const UW_FORM_TEMPLATE = "\n<!doctype html>\n<html lang=\"en\">\n\n<head>\n <meta charset=\"UTF-8\" />\n <meta name=\"viewport\" content=\"width=device-width, initial-scale=1.0\" />\n <title>FULL UW APPLICATION FORM</title>\n\n <link href=\"https://fonts.googleapis.com/css2?family=Hanuman:wght@100..900&family=Moul&display=swap\"\n rel=\"stylesheet\" />\n <script src=\"https://cdn.tailwindcss.com\"></script>\n\n <style>\n * {\n margin: 0;\n box-sizing: border-box;\n background: none;\n }\n\n body {\n font-family: \"Hanuman\", sans-serif;\n margin: 0;\n font-size: 16px;\n }\n\n .font-moul {\n font-family: \"Moul\", sans-serif;\n }\n\n .font-arial {\n font-family: Arial, sans-serif;\n }\n\n .form-table td {\n border: 1px solid black;\n }\n\n .no-border td {\n border-top: none !important;\n border-bottom: none !important;\n }\n\n .form-field-line {\n border-bottom: 1px solid #000;\n min-height: 18px;\n width: 100%;\n display: block;\n margin-top: 4px;\n }\n\n input[type=\"checkbox\"] {\n width: 18px;\n height: 18px;\n margin-right: 5px;\n vertical-align: middle;\n accent-color: #000;\n }\n\n @media print {\n @page {\n size: A3 portrait;\n margin: 10mm 10mm 0mm 10mm;\n }\n }\n\n .page {\n width: 297mm;\n /* A3 portrait width */\n min-height: 420mm;\n /* A3 portrait height */\n padding: 10mm;\n box-sizing: border-box;\n position: relative;\n page-break-after: always;\n break-after: page;\n overflow: hidden;\n }\n\n .question-row {\n page-break-inside: avoid;\n break-inside: avoid;\n }\n </style>\n\n</head>\n\n<% function yesNoCheckbox(value, name) { return '<div class=\"flex items-center gap-2\" style=\"margin-top:3px;\">' + '<input type=\"checkbox\" ' + (value===true ? 'checked' : '') + ' />' + '<span>\u1798\u17B6\u1793 / Yes</span>' + '&nbsp;&nbsp;' + '<input type=\"checkbox\" ' + (value===false ? 'checked' : '') + ' />' + '<span>\u1798\u17B7\u1793\u1798\u17B6\u1793 / No</span>' + '</div>';\n }\n %>\n\n\n <% function renderField(value) { const hasValue=value && value.toString().trim(); return '<div style=\"border-bottom:1px solid #000;min-height:18px;width:100%;display:block;margin-top:4px;\">' + (hasValue ? '<span style=\"font-weight:bold;\">' + value + '</span>' : '&nbsp;') + '</div>';\n } %>\n\n <% function renderCheck(value, expected) { return value===expected\n ? '<span style=\"font-size:16px; font-weight:bold;\">&#10003;</span>' : '' ; } %>\n\n <body>\n <script>\n document.fonts.ready.then(() => {\n paginateRows();\n });\n\n function paginateRows() {\n const PAGE_HEIGHT_PX = 1511;\n const wrapper = document.getElementById('pages-wrapper');\n const allRows = Array.from(document.querySelectorAll('.question-row'));\n\n let currentPage = document.getElementById('main-content');\n let currentTable = currentPage.querySelector('table');\n let currentDiv = currentPage;\n let usedHeight = currentPage.getBoundingClientRect().height;\n let pageNum = 1;\n\n function createNewPage() {\n pageNum++;\n const newPage = document.createElement('div');\n newPage.className = 'page';\n\n const newTable = document.createElement('table');\n newTable.className = 'table w-full table-fixed border-collapse form-table';\n newTable.setAttribute('cellpadding', '20');\n newPage.appendChild(newTable);\n wrapper.appendChild(newPage);\n\n currentTable = newTable;\n currentDiv = newPage;\n usedHeight = 0;\n }\n\n for (const row of allRows) {\n const isDeclaration = row.classList.contains('declaration-header');\n const isTr = row.tagName === 'TR';\n const container = isTr ? currentTable : currentDiv;\n\n // Measure\n row.style.visibility = 'hidden';\n container.appendChild(row);\n const rowH = row.getBoundingClientRect().height;\n container.removeChild(row);\n row.style.visibility = '';\n\n const remaining = PAGE_HEIGHT_PX - usedHeight;\n\n if (usedHeight + rowH > PAGE_HEIGHT_PX || (isDeclaration && remaining < 300)) {\n createNewPage();\n }\n\n const target = row.tagName === 'TR' ? currentTable : currentDiv;\n target.appendChild(row);\n usedHeight += rowH;\n }\n }\n </script>\n \n <div id=\"pages-wrapper\">\n <div class=\"page\">\n <div id=\"first-off-page\">\n <div class=\"space-y-3\">\n <table width=\"100%\" cellpadding=\"20\">\n <colgroup>\n <col style=\"width: 20%\" />\n <col style=\"width: 80%\" />\n </colgroup>\n <tr style=\"text-align:center;\">\n <th style=\"background:#ebebeb; border:1px solid;\">\n <img src=\"data:image/png;base64,<%= logo_base64 %>\" alt=\"Logo\" class=\"title-logo\" width=\"200px\" />\n </th>\n \n <th style=\"background:#dddddd; border:1px solid;\" class=\"space-y-2\">\n <p class=\"font-moul text-2xl\">\n \u1796\u17B6\u1780\u17D2\u1799\u179F\u17C1\u17B8\u17D2\u1793\u179F\u17BB\u17C6\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u17A2\u17B6\u1799\u17BB\u1787\u17B8\u179C\u17B7\u178F\n </p>\n <p class=\"text-lg\">\n LIFE ASSURANCE APPLICATION FORM\n </p>\n </th>\n </tr>\n </table>\n \n <div class=\"space-y-2 text-align\">\n <p>\u179F\u17BC\u1798\u1795\u17D2\u178F\u179B\u17CB\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u1798\u1780\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793\u17B1\u17D2\u1799\u1794\u17B6\u1793\u1782\u17D2\u179A\u1794\u17CB\u1782\u17D2\u179A\u17B6\u1793\u17CB \u1793\u17B7\u1784\u178F\u17D2\u179A\u17B9\u1798\u178F\u17D2\u179A\u17BC\u179C\u17D4 \u1780\u17B6\u179A\u1795\u17D2\u178F\u179B\u17CB\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u1798\u17B7\u1793\u178F\u17D2\u179A\u17B9\u1798\u178F\u17D2\u179A\u17BC\u179C \u17AC\u1780\u17D2\u179B\u17C2\u1784\u1794\u1793\u17D2\u179B\u17C6\n \u1793\u17B6\u17C6\u17B1\u17D2\u1799\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u1798\u17C4\u1783\u1797\u17B6\u1796 \u17AC\u178F\u17D2\u179A\u17BC\u179C\u179B\u17BB\u1794\u1785\u17C4\u179B\u17D4</p>\n <p>Please provide us with complete and accurate information. Providing wrong or false information may\n result\n in\n the policy issued being cancelled or voided.</p>\n </div>\n \n <table class=\"table w-full table-fixed border-collapse form-table\" cellpadding=\"10\">\n <colgroup>\n <col style=\"width: 17%\">\n <col style=\"width: 17%\">\n <col style=\"width: 8%\">\n <col style=\"width: 8%\">\n <col style=\"width: 17%\">\n <col style=\"width: 17%\">\n <col style=\"width: 8%\">\n <col style=\"width: 8%\">\n </colgroup>\n <thead>\n <tr>\n <th colspan=\"4\" class=\"w-1/2 border border-black\">\n <p>\u1795\u17D2\u1793\u17C2\u1780\u1791\u17B8\u17E1: \u200B\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u17A2\u17C6\u1796\u17B8\u1798\u17D2\u1785\u17B6\u179F\u17CB\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784</p>\n <p>Part 1: INFORMATION ABOUT THE POLICYHOLDER</p>\n </th>\n \n <th colspan=\"4\" class=\"w-1/2 border border-black\">\n <p>\u1795\u17D2\u1793\u17C2\u1780\u1791\u17B8\u17E1: \u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u17A2\u17C6\u1796\u17B8\u17A2\u17D2\u1793\u1780\u178F\u17D2\u179A\u17BC\u179C\u1794\u17B6\u1793\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784</p>\n <p>( \u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17C1\u17B8\u1781\u17BB\u179F\u1796\u17B8\u1798\u17D2\u1785\u17B6\u179F\u17CB\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784 )</p>\n <p>Part 1: INFORMATION ABOUT THE LIFE ASSURED</p>\n <p>( if different from the policyholder )</p>\n </th>\n </tr>\n \n <!-- Full Name Value -->\n <tr>\n <td colspan=\"4\">\n <p>\u1788\u17D2\u1798\u17C1\u17B6\u17C7\u1796\u17C1\u1789\u178A\u17BC\u1785\u1794\u1784\u17D2\u17A0\u17B6\u1789\u1793\u17C5\u1780\u17D2\u1793\u17BB\u1784\u17A2\u178F\u17D2\u178F\u179F\u1789\u17D2\u1789\u17B6\u178E\u1794\u178E\u17D2\u178E / \u179B\u17B7\u1781\u17B7\u178F\u1786\u17D2\u179B\u1784\u178A\u17C2\u1793 / \u179F\u17C6\u1794\u17BB\u178F\u17D2\u179A\u1780\u17C6\u178E\u17C1\u17B8\u178F / \u1794\u17D0\u178E\u17D2\u178E\u1794\u17C9\u17B6\u178F\u1784\u17CB\n (\u1787\u17B6\u1797\u17B6\u179F\u17B6\u1781\u17D2\u1798\u17C2\u179A \u1793\u17B7\u1784\u17A2\u1784\u17CB\u1782\u17D2\u179B\u17C1\u179F)</p>\n <p class=\" \">Full name as shown in ID card / Passport / Birth Certificate / Patent Tax (Khmer\n and\n English)</p>\n </td>\n <td colspan=\"4\">\n <p>\u1788\u17D2\u1798\u17C1\u17B6\u17C7\u1796\u17C1\u1789\u178A\u17BC\u1785\u1794\u1784\u17D2\u17A0\u17B6\u1789\u1793\u17C5\u1780\u17D2\u1793\u17BB\u1784\u17A2\u178F\u17D2\u178F\u179F\u1789\u17D2\u1789\u17B6\u178E\u1794\u178E\u17D2\u178E / \u179B\u17B7\u1781\u17B7\u178F\u1786\u17D2\u179B\u1784\u178A\u17C2\u1793 / \u179F\u17C6\u1794\u17BB\u178F\u17D2\u179A\u1780\u17C6\u178E\u17C1\u17B8\u178F (\u1787\u17B6\u1797\u17B6\u179F\u17B6\u1781\u17D2\u1798\u17C2\u179A\n \u1793\u17B7\u1784\u17A2\u1784\u17CB\u1782\u17D2\u179B\u17C1\u179F)</p>\n <p class=\" \">Full name as shown in ID card / Passport / Birth Certificate (Khmer and English)\n </p>\n </td>\n </tr>\n <tr>\n <td colspan=\"4\">\n <span class=\"font-bold text-md\">\n <%= ph.full_name %>\n </span>\n </td>\n <td colspan=\"4\">\n <span class=\"font-bold text-md\">\n <%= la.full_name %>\n </span>\n </td>\n </tr>\n \n <!-- Present Address Label -->\n <tr>\n <td colspan=\"4\">\n <span class=\"\">\u17A2\u17B6\u179F\u1799\u178A\u17D2\u178B\u17B6\u1793\u1794\u1785\u17D2\u1785\u17BB\u1794\u17D2\u1794\u1793\u17D2\u1793 /</span>\n <span class=\" \">Present Address</span>\n </td>\n <td colspan=\"4\">\n <span class=\"\">\u17A2\u17B6\u179F\u1799\u178A\u17D2\u178B\u17B6\u1793\u1794\u1785\u17D2\u1785\u17BB\u1794\u17D2\u1794\u1793\u17D2\u1793 /</span>\n <span class=\" \">Present Address</span>\n </td>\n </tr>\n <tr>\n <td colspan=\"4\">\n <span class=\"font-bold\">\n <%= ph.present_address %>\n </span>\n </td>\n <td colspan=\"4\">\n <span class=\"font-bold\">\n <%= la.present_address %>\n </span>\n </td>\n </tr>\n \n <!-- Phone / Relationship Label -->\n <tr>\n <td colspan=\"4\">\n <ol class=\"list-decimal pl-5\">\n <li>\n <span>\u179B\u17C1\u1781\u1791\u17BC\u179A\u179F\u17D0\u1796\u17D2\u1791\u1795\u17D2\u1791\u17B6\u179B\u17CB\u1781\u17D2\u179B\u17BD\u1793 / \u17A2\u17BB\u17B8\u1798\u17C9\u17C2\u179B /</span>\n <span>Phone Number / Email</span>\n </li>\n <li>\n <span>\u1791\u17C6\u1793\u17B6\u1780\u17CB\u1791\u17C6\u1793\u1784\u1787\u17B6\u1798\u17BD\u1799\u17A2\u17D2\u1793\u1780\u178F\u17D2\u179A\u17BC\u179C\u1794\u17B6\u1793\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784 /</span>\n <span>Relationship to Life Assured</span>\n </li>\n </ol>\n </td>\n \n <td colspan=\"4\">\n <ol class=\"list-decimal pl-5\">\n <li>\n <span>\u179B\u17C1\u1781\u1791\u17BC\u179A\u179F\u17D0\u1796\u17D2\u1791\u1795\u17D2\u1791\u17B6\u179B\u17CB\u1781\u17D2\u179B\u17BD\u1793 / \u17A2\u17BB\u17B8\u1798\u17C9\u17C2\u179B /</span>\n <span>Phone Number / Email</span>\n </li>\n <li>\n <span>\u1791\u17C6\u1793\u17B6\u1780\u17CB\u1791\u17C6\u1793\u1784\u1787\u17B6\u1798\u17BD\u1799\u1798\u17D2\u1785\u17B6\u179F\u17CB\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784 /</span>\n <span>Relationship to Policyholder</span>\n </li>\n </ol>\n </td>\n </tr>\n \n <tr class=\"font-bold\">\n <td colspan=\"4\">\n <ol class=\"list-decimal pl-5\">\n <li>\n <span>Primary Contact: <%= ph.contact_info %> </span>\n </li>\n <li>\n <span>\n <%= ph.ph_la_relationship %>\n </span>\n </li>\n </ol>\n </td>\n \n <td colspan=\"4\">\n <ol class=\"list-decimal pl-5\">\n <li>\n <span>Primary Contact: <%= la.contact_info %> </span>\n </li>\n <li>\n <span>\n <%= la.ph_la_relationship %>\n </span>\n </li>\n </ol>\n </td>\n </tr>\n \n <!-- PH = LA / PH \u2260 LA -->\n <tr>\n <td colspan=\"4\">\n <div class=\"flex items-center gap-2\">\n <input type=\"checkbox\" <%=isphla_same_person ? 'checked' : '' %> />\n <span>\u1798\u17D2\u1785\u17B6\u179F\u17CB\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784 = \u17A2\u17D2\u1793\u1780\u178F\u17D2\u179A\u17BC\u179C\u1794\u17B6\u1793\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784</span>\n <span>/</span>\n <span>PH = LA</span>\n </div>\n </td>\n <td colspan=\"4\">\n <div class=\"flex items-center gap-2\">\n <input type=\"checkbox\" <%=!isphla_same_person ? 'checked' : '' %> />\n <span>\u1798\u17D2\u1785\u17B6\u179F\u17CB\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784 </span> &ne; <span>\u17A2\u17D2\u1793\u1780\u178F\u17D2\u179A\u17BC\u179C\u1794\u17B6\u1793\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784</span>\n <span>/</span>\n <span>PH \u2260 LA</span>\n </div>\n </td>\n </tr>\n \n <!-- Nationality / ID / Gender / Age Labels -->\n <% const headers=[ { kh: \"\u179F\u1789\u17D2\u1787\u17B6\u178F\u17B7\" , en: \"Nationality\" }, { kh: \"\u179B\u17C1\u1781\u17A2\u178F\u17D2\u178F\u179F\u1789\u17D2\u1789\u17B6\u178E\u1794\u17D0\u178E\u17D2\u178E/\u179B\u17B7\u1781\u17B7\u178F\u1786\u17D2\u179B\u1784\u178A\u17C2\u1793\" ,\n en: \"ID / Passport Number\" }, { kh: \"\u1797\u17C1\u1791\" , en: \"Gender\" }, { kh: \"\u17A2\u17B6\u1799\u17BB\" , en: \"Age\" } ]; %>\n \n <tr>\n <% for (let i=0; i < 2; i++) { %>\n <% headers.forEach((h, idx)=> { %>\n \n <td class=\"align-top <%= idx === headers.length - 1 ? 'text-center' : 'text-start' %>\">\n <div class=\"flex flex-col justify-center h-full\">\n <p class=\"text-sm\">\n <%= h.kh %>\n </p>\n <p class=\"text-sm\">\n <%= h.en %>\n </p>\n </div>\n </td>\n \n <% }) %>\n <% } %>\n </tr>\n \n <!-- Nationality / ID / Gender / Age Values -->\n <tr>\n <td class=\"text-start-top\">\n <p class=\"font-bold\">\n <%= ph.nationality %>\n </p>\n </td>\n <td class=\"text-start-top\">\n <p class=\"font-bold\">\n <%= ph.identifier_no %>\n </p>\n </td>\n <td class=\"text-start-top\">\n <p class=\"font-bold\">\n <%= ph.gender %>\n </p>\n </td>\n <td class=\"text-start-top text-center\">\n <span class=\"font-bold\">\n <%= ph.age %>\n </span>\n </td>\n \n <td class=\"text-start-top\">\n <p class=\"font-bold\">\n <%= la.nationality %>\n </p>\n </td>\n <td class=\"text-start-top\">\n <p class=\" font-bold\">\n <%= la.identifier_no %>\n </p>\n </td>\n <td class=\"text-start-top\">\n <p class=\"font-bold\">\n <%= la.gender %>\n </p>\n </td>\n <td class=\"text-start-top text-center\">\n <span class=\"font-bold \">\n <%= la.age %>\n </span>\n </td>\n </tr>\n \n <!-- DOB / Marital / Children Labels -->\n <% const fields=[ { kh: \"\u1790\u17D2\u1784\u17C3\u1781\u17C2\u1786\u17D2\u1793\u17B6\u17C6 \u1793\u17B7\u1784\u1791\u17B8\u1780\u1793\u17D2\u179B\u17C2\u1784\u1780\u17C6\u178E\u17BE\u178F\" , en: \"Date and Place of Birth\" , colspan: 1 }, {\n kh: \"\u1793\u17C5\u179B\u17B8\u179C / \u179A\u17C0\u1794\u1780\u17B6\u179A\u179A\u17BD\u1785 / \u179B\u17C2\u1784\u179B\u17C7 / \u1796\u17C4\u17C7\u1798\u17C9\u17B6\u1799 \u17AC\u1798\u17C1\u1798\u17C9\u17B6\u1799\" , en: \"Single / Married / Divorced / Widowed\" , colspan: 1 }, {\n kh: \"\u1785\u17C6\u1793\u17BD\u1793\u1780\u17BC\u1793\" , en: \"Number of Children\" , colspan: 2 } ]; %>\n \n <tr>\n <% for (let i=0; i < 2; i++) { %>\n <% fields.forEach(field=> { %>\n\n <td colspan=\"<%= field.colspan %>\" class=\"text-start-top align-top\">\n <p class=\"text-sm\">\n <%= field.kh %>\n </p>\n <p class=\"text-sm\">\n <%= field.en %>\n </p>\n </td>\n \n <% }) %>\n <% } %>\n </tr>\n \n <tr>\n <td class=\"text-start-top\" style=\"line-height:1.7\">\n <p class=\"font-bold text-sm\">\n <%= ph.dob_and_pob || '' %>\n </p>\n </td>\n <td class=\"text-start-top text-center\">\n <p class=\"font-bold\">\n <%= ph.martial_status %>\n </p>\n </td>\n <td colspan=\"2\" class=\"text-start-top text-center\">\n <p class=\" font-bold\">\n <%= ph.number_of_children %>\n </p>\n </td>\n \n <td class=\"text-start-top\" style=\"line-height:1.7\">\n <p class=\"font-bold text-sm\">\n <%= la.dob_and_pob || '' %>\n </p>\n </td>\n <td class=\"text-start-top text-center\">\n <p class=\" font-bold\">\n <%= la.martial_status %>\n </p>\n </td>\n <td colspan=\"2\" class=\"text-start-top text-center\">\n <p class=\" font-bold\">\n <%= la.number_of_children %>\n </p>\n </td>\n </tr>\n \n <!-- Employer Name Label -->\n <tr>\n <td colspan=\"4\">\n <span>\u1788\u17D2\u1798\u17C4\u17C7 \u1793\u17B7\u1784\u17A2\u17B6\u179F\u1799\u178A\u17D2\u178B\u17B6\u1793\u179A\u1794\u179F\u17CB\u1793\u17B7\u1799\u17C4\u1787\u1780 /</span>\n <span>Name and Address of Employer</span>\n </td>\n <td colspan=\"4\">\n <span>\u1788\u17D2\u1798\u17C4\u17C7 \u1793\u17B7\u1784\u17A2\u17B6\u179F\u1799\u178A\u17D2\u178B\u17B6\u1793\u179A\u1794\u179F\u17CB\u1793\u17B7\u1799\u17C4\u1787\u1780 /</span>\n <span>Name and Address of Employer</span>\n </td>\n </tr>\n \n <!-- Employer Name Value -->\n <tr>\n <td colspan=\"4\">\n <span class=\"font-khmer font-bold\">\n <%= ph.name_and_address_of_employer || 'N/A' %>\n </span>\n </td>\n <td colspan=\"4\">\n <span class=\"font-khmer font-bold\">\n <%= la.name_and_address_of_employer || 'N/A' %>\n </span>\n </td>\n </tr>\n \n <!-- Job Title / Salary Labels -->\n <% const jobFields=[ { kh: \"\u178F\u17BD\u1793\u17B6\u1791\u17B8 \u1793\u17B7\u1784\u1794\u17D2\u179A\u1797\u17C1\u1791\u1793\u17C3\u1780\u17B6\u179A\u1784\u17B6\u179A\" , en: \"Job Title and Nature of Work\" , colspan: 2 }, {\n kh: \"\u1794\u17D2\u179A\u17B6\u1780\u17CB\u1794\u17C0\u179C\u178F\u17D2\u179F\u1794\u17D2\u179A\u1785\u17C6\u17B6\u1786\u17D2\u1793\u17B6\u17C6\" , en: \"Annual Salary\" , colspan: 2 } ]; %>\n <tr>\n <% for (let i=0; i < 2; i++) { %>\n <% jobFields.forEach(field=> { %>\n <td colspan=\"<%= field.colspan %>\">\n <p>\n <%= field.kh %>\n </p>\n <p>\n <%= field.en %>\n </p>\n </td>\n <% }) %>\n <% } %>\n </tr>\n \n <!-- Job Title / Salary Values -->\n <tr>\n <td colspan=\"2\"><span class=\"font-khmer font-bold\">\n <%= ph.job_title %>\n </span></td>\n <td colspan=\"2\"><span class=\"font-khmer font-bold\">\n <%= ph.annual_salary %>\n </span></td>\n \n <td colspan=\"2\"><span class=\"font-khmer font-bold\">\n <%= la.job_title %>\n </span></td>\n <td colspan=\"2\"><span class=\"font-khmer font-bold\">\n <%= la.annual_salary %>\n </span></td>\n </tr>\n <!-- USA Green Card -->\n <tr>\n <td colspan=\"8\">\n <span>\u1798\u17D2\u1785\u17B6\u179F\u17CB\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u1798\u17B7\u1793\u1798\u17C2\u1793\u1787\u17B6\u1796\u179B\u179A\u178A\u17D2\u178B\u17A2\u17B6\u1798\u17C1\u179A\u17B7\u1780 \u17AC \u1787\u17B6\u1794\u17CB\u1796\u1793\u17D2\u1792\u179F\u17D2\u1793\u17B6\u1780\u17CB\u1793\u17C5\u17A2\u17B6\u1798\u17C1\u179A\u17B7\u1780 \u17AC\n \u1798\u17B6\u1793\u179F\u17B7\u1791\u17D2\u1792\u17B7\u1780\u17B6\u1793\u17CB</span>\n <span> Green Card </span>\n <span>\u1793\u17C4\u17C7\u1791\u17C1\u17D4 </span>\n <p>\n <span>The Policyholder is not USA citizen / USA resident for tax purpose or holding\n Green\n Card.</span>\n </p>\n <%- yesNoCheckbox(ph_is_not_us_citizen) %>\n </td>\n </tr>\n </thead>\n </table>\n </div>\n \n <!-- page break -->\n <div style=\"page-break-after: always;\"></div>\n <!-- table 2 question -->\n <table class=\"table w-full table-fixed border-collapse form-table\" cellpadding=\"10\">\n <colgroup>\n <col style=\"width: 40%\">\n <col style=\"width: 30%\">\n <col style=\"width: 30%\">\n </colgroup>\n <!-- Only Life Assured Notice -->\n <tr>\n <td colspan=\"3\" class=\"text-lg font-bold\" style=\"text-align:center;\">\n <h5>\n \u17A2\u17D2\u1793\u1780\u178F\u17D2\u179A\u17BC\u179C\u1794\u17B6\u1793\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u178F\u17C2\u1794\u17C9\u17BB\u178E\u17D2\u178E\u17C4\u17C7\u178A\u17C2\u179B\u178F\u1798\u17D2\u179A\u17BC\u179C\u17B1\u17D2\u1799\u1794\u17C6\u1796\u17C1\u1789\u1795\u17D2\u1793\u17C2\u1780\u178A\u17C2\u179B\u1793\u17C5\u179F\u179B\u17CB\u1793\u17C3\u1791\u1798\u17D2\u179A\u1784\u17CB\u1796\u17B6\u1780\u17D2\u1799\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u1793\u17C1\u17C7</h5>\n <h5>ONLY THE LIFE ASSURED'S INFORMATION IS REQUIRED FOR THE REMAINDER OF THIS\n APPLICATION FORM</h5>\n </td>\n </tr>\n \n <tr>\n <td colspan=\"3\">\n <span>\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u17A2\u17C6\u1796\u17B8\u179A\u1794\u17C0\u1794\u179A\u179F\u17CB\u1793\u17C5 \u1793\u17B7\u1784\u17A0\u17B6\u1793\u17B7\u1797\u17D0\u1799</span> / <span>Lifestyle and Risk Information</span>\n </td>\n </tr>\n \n <!-- Dangerous Activities -->\n \n <!-- Military Flying -->\n <tr class=\"no-border\">\n <td colspan=\"3\">\n <p>\u178F\u17BE\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u1780\u17C6\u1796\u17BB\u1784 \u17AC\u1798\u17B6\u1793\u1782\u1798\u17D2\u179A\u17C4\u1784\u1792\u17D2\u179C\u17BE\u1780\u17B6\u179A\u17A0\u17C4\u17C7\u17A0\u17BE\u179A\u1787\u17B6\u179B\u1780\u17D2\u1781\u178E\u17C8\u1799\u17C4\u1792\u17B6 \u17AC\u17AF\u1780\u1787\u1793\n \u1780\u17D2\u179A\u17C5\u1796\u17B8\u17A2\u17D2\u1793\u1780\u178A\u17C6\u178E\u17BE\u179A\u178F\u17B6\u1798\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793\u17A2\u17B6\u1780\u17B6\u179F\u1785\u179A\u178E\u17CD\u1792\u1798\u17D2\u1798\u178F\u17B6\u178A\u17C2\u179A\u17AC\u1791\u17C1?</p>\n \n <p>Do you take part in or do you plan to take part in military or private flying other\n than as a passenger on a regular airline?</p>\n \n <%- yesNoCheckbox(la_lifestyle.military_or_flying) %>\n </td>\n </tr>\n \n <!-- Dangerous Occupations Header -->\n <tr class=\"no-border\">\n <td colspan=\"3\">\n <p>\u178F\u17BE\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u1780\u17C6\u1796\u17BB\u1784 \u17AC\u1798\u17B6\u1793\u1782\u1798\u17D2\u179A\u17C4\u1784\u1793\u17B9\u1784\u1798\u17B6\u1793\u17A2\u17B6\u1787\u17B8\u1796\n \u17AC\u1792\u17D2\u179C\u17BE\u179F\u1780\u1798\u17D2\u1798\u1797\u17B6\u1796\u1782\u17D2\u179A\u17C4\u17C7\u1790\u17D2\u1793\u17B6\u1780\u17CB\u178A\u17BC\u1785\u1798\u17B6\u1793\u179A\u17C0\u1794\u179A\u17B6\u1794\u17CB\u1793\u17C5\u1781\u17B6\u1784\u1780\u17D2\u179A\u17C4\u1798\u1793\u17C1\u17C7\u178A\u17C2\u179A\u17AC\u1791\u17C1?</p>\n <p>Do you take part in, or plan to take part in any of these listed dangerous occupations or\n pursuits?</p>\n </td>\n </tr>\n \n <!-- Scuba / Rock Climbing -->\n <tr class=\"no-border\">\n <td colspan=\"3\">\n <span>\u1787\u17D2\u179A\u1798\u17BB\u1787\u1791\u17B9\u1780\u1782\u17D2\u179A\u1794\u17CB\u1794\u17D2\u179A\u1797\u17C1\u1791 \u17A1\u17BE\u1784\u1790\u17D2\u1798 \u17AC\u17A1\u17BE\u1784\u1797\u17D2\u1793\u17C6 / Scuba Skin diving Mountain or rock climbing</span>\n <%- yesNoCheckbox(la_lifestyle.diving_or_climbing) %>\n </td>\n </tr>\n \n <!-- Parachuting / Motor Racing -->\n <tr class=\"no-border\">\n <td colspan=\"3\">\n <span>\u179B\u17C4\u178F\u1786\u17D0\u178F\u17D2\u179A\u1799\u17C4\u1784 \u1794\u17D2\u179A\u178E\u17B6\u17C6\u1784\u1798\u17C9\u17BC\u178F\u17BC / Free fall parachuting Motor racing</span>\n <%- yesNoCheckbox(la_lifestyle.parachuting_or_racing) %>\n </td>\n </tr>\n \n <!-- Other -->\n <tr class=\"no-border\">\n <td colspan=\"3\">\n <span>\u1795\u17D2\u179F\u17C1\u1784\u17D7\u1791\u17C0\u178F \u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17BE\u1798\u17B6\u1793\u179F\u17BC\u1798\u1794\u1789\u17D2\u1787\u17B6\u1780\u17CB / Other if yes please provide more details : <%-\n renderField(la_lifestyle.activity_detail_desc) %></span>\n </td>\n </tr>\n \n <!-- Travel Abroad -->\n <tr class=\"no-border border-t border-black\">\n <td colspan=\"3\">\n <p>\u178F\u17BE\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u179F\u17D2\u1793\u17B6\u1780\u17CB\u1793\u17C5 \u17AC \u1798\u17B6\u1793\u1782\u1798\u17D2\u179A\u17C4\u1784\u179F\u17D2\u1793\u17B6\u1780\u17CB\u1793\u17C5\u1780\u17D2\u179A\u17C5\u1794\u17D2\u179A\u1791\u17C1\u179F\u179B\u17BE\u179F\u1796\u17B8\u179A\u1799\u17C8\u1796\u17C1\u179B\u17E3\u1781\u17C2 \u1780\u17D2\u1793\u17BB\u1784\u17E1\u1786\u17D2\u1793\u17B6\u17C6\u178A\u17C2\u179A\u17AC\u1791\u17C1?</p>\n <p>Do you plan to reside or travel abroad for more than three months a year?</p>\n <%- yesNoCheckbox(la_lifestyle.reside_or_travel_abroad) %>\n </td>\n </tr>\n <tr class=\"no-border\">\n <td colspan=\"3\">\n <p>\u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17BE\u1798\u17B6\u1793\u179F\u17BC\u1798\u1795\u17D2\u178F\u179B\u17CB\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u179B\u1798\u17D2\u17A2\u17B7\u178F\u17A2\u17C6\u1796\u17B8\u17A2\u17B6\u179F\u1799\u178A\u17D2\u178B\u17B6\u1793\u179A\u1794\u179F\u17CB\u1794\u17D2\u179A\u1791\u17C1\u179F\u178A\u17C2\u179B\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u179F\u17D2\u1793\u17B6\u1780\u17CB\u1793\u17C5 \u17AC\n \u1798\u17B6\u1793\u1782\u1798\u17D2\u179A\u17C4\u1784\u179F\u17D2\u1793\u17B6\u1780\u17CB\u1793\u17C5 \u17AC\u1792\u17D2\u179C\u17BE\u178A\u17C6\u178E\u17BE\u179A\u178A\u17BC\u1785\u1781\u17B6\u1784\u1780\u17D2\u179A\u17C4\u1798:</p>\n <p class=\"mb-3\">\n If yes, please provide detail information about address of country that reside / travel as\n following :\n </p>\n <span> <%- renderField(la_lifestyle.travel_detail_desc) %></span>\n </td>\n </tr>\n \n \n <tr class=\"width-100\" cellpadding=\"10\">\n <td colspan=\"3\" style=\"text-align:center;\" class=\"text-lg font-bold\">\n <h5>\u1795\u17D2\u1793\u17C2\u1780\u1791\u17B8 \u17E2: \u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u17A2\u17C6\u1796\u17B8\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784</h5>\n <h5>Part 2: INFORMATION ABOUT THE POLICY</h5>\n </td>\n </tr>\n \n <!-- Policy Info Labels -->\n <tr>\n <td style=\"width:45%;\">\n <p>\u1794\u17D2\u179A\u1797\u17C1\u1791\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784 \u1793\u17B7\u1784\u179A\u1799\u17C8\u1796\u17C1\u179B\u1792\u17B6\u1793\u17B6</p>\n <p>Type of Policy and Length of Cover</p>\n </td>\n <td>\n <p>\u1791\u17B9\u1780\u1794\u17D2\u179A\u17B6\u1780\u17CB\u178F\u17D2\u179A\u17BC\u179C\u1794\u17B6\u1793\u1792\u17B6\u1793\u17B6</p>\n <p>(\u178A\u17BB\u179B\u17D2\u179B\u17B6\u179A\u17A2\u17B6\u1798\u17C1\u179A\u17B7\u1780)</p>\n <p>Sum Assured (USD)</p>\n </td>\n <td>\n <p>\u1794\u17BB\u1796\u17D2\u179C\u179B\u17B6\u1797\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u178A\u17C2\u179B\u178F\u17D2\u179A\u17BC\u179C\u1794\u1784\u17CB</p>\n <p>(\u178A\u17BB\u179B\u17D2\u179B\u17B6\u179A\u17A2\u17B6\u1798\u17C1\u179A\u17B7\u1780)</p>\n <p>Premium Payable (USD)</p>\n </td>\n </tr>\n \n <!-- Policy Info Values -->\n <% policy_info.products.forEach(product=> { %>\n <tr class=\"text-md\">\n <td>\n <b>\n <%= product.product %>\n </b>\n </td>\n <td>\n <b>\n <%= product.sum_assured %>\n </b>\n </td>\n <td>\n <b>\n <%= product.premium %>\n </b>\n </td>\n </tr>\n <% }) %>\n \n <!-- Rider Details -->\n \n <tr>\n <td>\n <p>\n <span>\u17A2\u17C6\u1796\u17B8\u1782\u1798\u17D2\u179A\u17C4\u1784\u1794\u1793\u17D2\u1790\u17C2\u1798 / Details of Rider: </span>\n </p>\n <p class=\"text-md font-bold\">\n <%= policy_info.rider.product || 'N/A' %>\n </p>\n </td>\n <td class=\"text-md\">\n <b>\n <%= policy_info.rider.sum_assured || '-' %>\n </b>\n </td>\n <td class=\"text-md\">\n <b>\n <%= policy_info.rider.premium || '-' %>\n </b>\n </td>\n </tr>\n <!-- Total Premium -->\n <tr>\n <td colspan=\"2\" style=\"text-align:right;\">\n <p class=\"font-bold text-md\">\n \u1794\u17BB\u1796\u17D2\u179C\u179B\u17B6\u1797\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u179F\u179A\u17BB\u1794(\u178A\u17BB\u179B\u17D2\u179B\u17B6\u179A\u17A2\u17B6\u1798\u17C1\u179A\u17B7\u1780) / Total Premium (USD)\n </p>\n </td>\n <td class=\"text-md\">\n <b>\n <%= policy_info.total_premium %>\n </b>\n </td>\n </tr>\n </table>\n <!-- table 3 payment -->\n <table class=\"width-100 form-table\" style=\"margin-top:10px;\" cellpadding=\"10\">\n <tr>\n \n <!-- Premium Payment Label -->\n <td style=\"vertical-align:top;width:15%;\">\n <p>\u1794\u17BB\u1796\u17D2\u179C\u179B\u17B6\u1797\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u178A\u17C2\u179B\u178F\u17D2\u179A\u17BC\u179C\u1794\u1784\u17CB (\u1787\u17D2\u179A\u17BE\u179F\u179A\u17BE\u179F)</p>\n <p>Premium Payment (select):</p>\n </td>\n \n <!-- Premium Payment Options -->\n <td style=\"vertical-align:top;width:18%;\">\n \n <!-- Single Premium -->\n <div style=\"display:flex;align-items:flex-start;gap:6px;margin-top:4px;\">\n <input type=\"checkbox\" <%=policy_info.payment_mode==='Single' ? 'checked' : '' %>\n style=\"margin-top:3px;flex-shrink:0;\" />\n <span>\u1794\u17BB\u1796\u17D2\u179C\u179B\u17B6\u1797\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u1794\u1784\u17CB\u1798\u17BD\u1799\u179B\u17BE\u1780 / Single Premium</span>\n </div>\n \n <!-- Annually -->\n <div style=\"display:flex;align-items:flex-start;gap:6px;margin-top:6px;\">\n <input type=\"checkbox\" <%=policy_info.payment_mode==='Annually' ? 'checked' : '' %>\n style=\"margin-top:3px;flex-shrink:0;\" />\n <span>\u1794\u17D2\u179A\u1785\u17B6\u17C6\u1786\u17D2\u1793\u17B6\u17C6 / Annually</span>\n </div>\n \n <!-- Semi-Annually -->\n <div style=\"display:flex;align-items:flex-start;gap:6px;margin-top:6px;\">\n <input type=\"checkbox\" <%=policy_info.payment_mode==='Semi-Annually' ? 'checked' : '' %>\n style=\"margin-top:3px;flex-shrink:0;\" />\n <span>\u1794\u17D2\u179A\u1785\u17B6\u17C6\u1786\u1798\u17B6\u179F / Semi-Annually</span>\n </div>\n \n <!-- Quarterly -->\n <div style=\"display:flex;align-items:flex-start;gap:6px;margin-top:6px;\">\n <input type=\"checkbox\" <%=policy_info.payment_mode==='Quarterly' ? 'checked' : '' %>\n style=\"margin-top:3px;flex-shrink:0;\" />\n <span>\u1794\u17D2\u179A\u1785\u17B6\u17C6\u178F\u17D2\u179A\u17B8\u1798\u17B6\u179F / <span>Quarterly</span></span>\n </div>\n \n <!-- Monthly -->\n <div style=\"display:flex;align-items:flex-start;gap:6px;margin-top:6px;\">\n <input type=\"checkbox\" <%=policy_info.payment_mode==='Monthly' ? 'checked' : '' %>\n style=\"margin-top:3px;flex-shrink:0;\" />\n <span>\u1794\u17D2\u179A\u1785\u17B6\u17C6\u1781\u17C2 / Monthly</span>\n </div>\n \n </td>\n \n <!-- Method of Payment Label -->\n <td style=\"vertical-align:top;width:12.7%;\">\n <p>\u179A\u1794\u17C0\u1794\u1793\u17C3\u1780\u17B6\u179A\u1794\u1784\u17CB (\u1787\u17D2\u179A\u17BE\u179F\u179A\u17BE\u179F)</p>\n <p>Method of Payment (select)</p>\n </td>\n \n <!-- Method of Payment Options -->\n <td style=\"vertical-align:top;text-align:left;width:20%;\">\n \n <!-- Direct Debit -->\n <div style=\"display:flex;align-items:flex-start;gap:6px;margin-top:4px;\">\n <input type=\"checkbox\" <%=policy_info.payment_method==='Direct Debit' ? 'checked' : '' %>\n style=\"margin-top:3px;flex-shrink:0;\" />\n <span>\u17A5\u178E\u1796\u1793\u17D2\u1792\u1795\u17D2\u1791\u17B6\u179B\u17CB / <span>Direct Debit</span></span>\n </div>\n \n <!-- Bank Transfer -->\n <div style=\"display:flex;align-items:flex-start;gap:6px;margin-top:6px;\">\n <input type=\"checkbox\" <%=policy_info.payment_method==='Bank Transfer' ? 'checked' : '' %>\n style=\"margin-top:3px;flex-shrink:0;\" />\n <span>\u1795\u17D2\u1791\u17C1\u179A\u178F\u17B6\u1798\u179A\u1799\u17C8\u1792\u1793\u17B6\u1782\u17B6\u179A / <span>Bank Transfer</span></span>\n </div>\n \n <!-- Cheque -->\n <div style=\"display:flex;align-items:flex-start;gap:6px;margin-top:6px;\">\n <input type=\"checkbox\" <%=policy_info.payment_method==='Cheque' ? 'checked' : '' %>\n style=\"margin-top:3px;flex-shrink:0;\" />\n <span>\u1798\u17BC\u179B\u1794\u17D2\u1794\u1791\u17B6\u1793\u1794\u17D0\u178F\u17D2\u179A / <span>Cheque</span></span>\n </div>\n \n <!-- Cash -->\n <div style=\"display:flex;align-items:flex-start;gap:6px;margin-top:6px;\">\n <input type=\"checkbox\" <%=policy_info.payment_method==='Cash' ? 'checked' : '' %>\n style=\"margin-top:3px;flex-shrink:0;\" />\n <span>\u179F\u17B6\u1785\u17CB\u1794\u17D2\u179A\u17B6\u1780\u17CB / <span>Cash</span></span>\n </div>\n \n <!-- Credit Card -->\n <div style=\"display:flex;align-items:flex-start;gap:6px;margin-top:6px;\">\n <input type=\"checkbox\" <%=policy_info.payment_method==='Credit Card' ? 'checked' : '' %>\n style=\"margin-top:3px;flex-shrink:0;\" />\n <span>\u1794\u17D0\u178E\u17D2\u178E\u17A5\u178E\u1791\u17B6\u1793 / <span>Credit Card</span></span>\n </div>\n \n <!-- Other -->\n <div style=\"display:flex;align-items:flex-start;gap:6px;margin-top:6px;\">\n <input type=\"checkbox\" <%=policy_info.payment_method==='Other' ? 'checked' : '' %>\n style=\"margin-top:3px;flex-shrink:0;\" />\n <span>\u1795\u17D2\u179F\u17C1\u1784\u17D7 / Other</span>\n </div>\n \n </td>\n \n <!-- Direct Debit / Cheque / Credit Card Details -->\n <td colspan=\"4\" style=\"vertical-align:top;\">\n \n <!-- Direct Debit and Cheques -->\n <div>\n <p>\u17A5\u178E\u1796\u1793\u17D2\u1792\u1795\u17D2\u1791\u17B6\u179B\u17CB \u1793\u17B7\u1784\u1798\u17BC\u179B\u1794\u17D2\u1794\u1791\u17B6\u1793\u1794\u17D0\u178F\u17D2\u179A /</p>\n <p>Direct Debit and Cheques:</p>\n </div>\n \n <!-- Bank Name / Cheque No -->\n <div style=\"margin-top:4px;\">\n <p>\u179F\u17BC\u1798\u1795\u17D2\u178F\u179B\u17CB\u1788\u17D2\u1798\u17C4\u17C7\u1792\u1793\u17B6\u1782\u17B6\u179A \u1793\u17B7\u1784\u179F\u17B6\u1781\u17B6\u1792\u1793\u17B6\u1782\u17B6\u179A / \u179B\u17C1\u1781\u1798\u17BC\u179B\u1794\u17D2\u1794\u1791\u17B6\u1793\u1794\u17D0\u178F\u17D2\u179A</p>\n <p>Please provide bank name and branch / cheque no.</p>\n <%- policy_info.cheque_info ? '<p><u><b>' + policy_info.cheque_info + '</b></u></p>'\n : '<div style=\"border-bottom:1px solid #000;min-height:18px;width:100%;display:block;margin-top:4px;\"></div>'\n %>\n </div>\n \n <!-- Credit Card Number -->\n <div style=\"margin-top:4px;\">\n <p>\u1794\u17D0\u178E\u17D2\u178E\u17A5\u178E\u1791\u17B6\u1793 \u179F\u17BC\u1798\u1795\u17D2\u178F\u179B\u17CB\u179B\u17C1\u1781\u1794\u17D0\u178E\u17D2\u178E\u17A5\u178E\u1791\u17B6\u1793</p>\n <p>Credit card please provide card number</p>\n <%- policy_info.credit_card_info ? '<p><u><b>' + policy_info.credit_card_info + '</b></u></p>'\n : '<div style=\"border-bottom:1px solid #000;min-height:18px;width:100%;display:block;margin-top:4px;\"></div>'\n %>\n </div>\n \n <!-- Card Type -->\n <div style=\"display:flex;align-items:center;gap:12px;margin-top:4px;flex-wrap:wrap;\">\n <div style=\"display:flex;align-items:center;gap:6px;\">\n <input type=\"checkbox\" <%=policy_info.credit_card_type==='Visa' ? 'checked' : '' %>\n style=\"flex-shrink:0;\"\n />\n <span>Visa</span>\n </div>\n <div style=\"display:flex;align-items:center;gap:6px;\">\n <input type=\"checkbox\" <%=policy_info.credit_card_type==='Master' ? 'checked' : '' %>\n style=\"flex-shrink:0;\"\n />\n <span>Master</span>\n </div>\n <div style=\"display:flex;align-items:center;gap:6px;\">\n <input type=\"checkbox\" <%=policy_info.credit_card_type==='American Express' ? 'checked' : '' %>\n style=\"flex-shrink:0;\" />\n <span>American Express</span>\n </div>\n </div>\n \n <!-- Expiry Date -->\n <div style=\"margin-top:4px;\">\n <span>\u1790\u17D2\u1784\u17C3\u1795\u17BB\u178F\u1780\u17C6\u178E\u178F\u17CB /</span>\n <span> Expiry Date:</span>\n <%- policy_info.credit_card_expiry_date ? '<p><u><b>' + policy_info.credit_card_expiry_date + '</b></u></p>'\n : '<div style=\"border-bottom:1px solid #000;min-height:18px;width:100%;display:block;margin-top:4px;\"></div>'\n %>\n </div>\n \n <!-- Other Method -->\n <div style=\"margin-top:4px;\">\n <span>\u1795\u17D2\u179F\u17C1\u1784\u1791\u17C0\u178F \u179F\u17BC\u1798\u1794\u1789\u17D2\u1787\u17B6\u1780\u17CB\u179C\u17B7\u1792\u17B8\u1794\u1784\u17CB\u1794\u17D2\u179A\u17B6\u1780\u17CB /</span>\n <span> Other indicate method of payment:</span>\n <%- policy_info.other_payment_method_desc ? '<p><u><b>' + policy_info.other_payment_method_desc + '</b></u></p>'\n : '<div style=\"border-bottom:1px solid #000;min-height:18px;width:100%;display:block;margin-top:4px;\"></div>'\n %>\n </div>\n </td>\n </tr>\n </table>\n <!-- page break -->\n <div style=\"page-break-after: always;\"></div>\n \n <!-- table 4 beneficiaries -->\n <table class=\"width-100 form-table\" style=\"margin-top:10px;\" cellpadding=\"10\">\n <colgroup>\n <col style=\"width: 25%;\" />\n <col style=\"width: 5%;\" />\n <col style=\"width: 20%;\" />\n <col style=\"width: 35%;\" />\n <col style=\"width: 15%;\" />\n </colgroup>\n \n <tr class=\"width-100\" cellpadding=\"10\">\n <td colspan=\"5\" style=\"text-align:center;\" class=\"text-lg font-bold\">\n <h5>\u1795\u17D2\u1793\u17C2\u1780\u1791\u17B8\u17E3: \u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u179A\u1794\u179F\u17CB\u17A2\u17D2\u1793\u1780\u1791\u1791\u17BD\u179B\u1795\u179B</h5>\n <h5>Part 3: BENEFICIARIES DETAILS</h5>\n </td>\n </tr>\n \n <tr class=\"text-start\">\n <td style=\"vertical-align: top;\">\n <p>\n \u1788\u17D2\u1798\u17C4\u17C7\u1796\u17C1\u1789\u179A\u1794\u179F\u17CB\u17A2\u17D2\u1793\u1780\u1791\u1791\u17BD\u179B\u1795\u179B\u1787\u17B6\u1797\u17B6\u179F\u17B6\u1781\u17D2\u1798\u17C2\u179A \u1793\u17B7\u1784\u17A2\u1784\u17CB\u1782\u17D2\u179B\u17C1\u179F\n </p>\n <p>\n Beneficiary's Full Name in Khmer and English\n </p>\n </td>\n \n <td style=\"vertical-align: top;\">\n <p>\u17A2\u17B6\u1799\u17BB</p>\n <p>Age</p>\n </td>\n \n <td style=\"vertical-align: top;\">\n <p>\u1791\u17C6\u1793\u17B6\u1780\u17CB\u1791\u17C6\u1793\u1784</p>\n <p>Relationship</p>\n </td>\n \n <td style=\"vertical-align: top;\">\n <p>\n \u179B\u17C1\u1781\u17A2\u178F\u17D2\u178F\u179F\u1789\u17D2\u1789\u17B6\u178E\u1794\u17D0\u178E\u17D2\u178E/\u179B\u17B7\u1781\u17B7\u178F\u1786\u17D2\u179B\u1784\u178A\u17C2\u1793/\u179F\u17C6\u1794\u17BB\u178F\u17D2\u179A\u1780\u17C6\u178E\u17BE\u178F\n </p>\n <p>\n ID, Passport, Birth Certificate Number\n </p>\n </td>\n \n <td style=\"vertical-align: top;\">\n <p>% \u1793\u17C3\u1780\u17B6\u179A\u1794\u17C2\u1784\u1785\u17C2\u1780</p>\n <p>% of Share</p>\n </td>\n </tr>\n \n <% beneficiaries.forEach(benefactor=> { %>\n <tr>\n <td>\n <p> <span><b>\n <%= benefactor.full_name %>\n </b></span> </p>\n </td>\n <td>\n <p> <span><b>\n <%= benefactor.age %>\n </b></span> </p>\n </td>\n <td>\n <p> <span><b>\n <%= benefactor.relationship %>\n </b></span> </p>\n </td>\n <td>\n <p> <span><b>\n <%= benefactor.identifier_and_birth_info %>\n </b></span> </p>\n </td>\n <td>\n <p> <span><b>\n <%= benefactor.percentage %>\n </b></span> </p>\n </td>\n </tr>\n <% }) %>\n \n <tr>\n <td colspan=\"4\" style=\"text-align:right\">\n <span>% \u179F\u179A\u17BB\u1794 /</span>\n <span>Total %</span>\n </td>\n <td> <b>100%</b> </td>\n </tr>\n \n <tr>\n <td colspan=\"5\">\n <p>\n <span>\n \u1780\u17C6\u178E\u178F\u17CB\u179F\u1798\u17D2\u1782\u17B6\u179B\u17CB\u17D6 \u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17BE\u1797\u17B6\u1782\u179A\u1799\u1798\u17B7\u1793\u1794\u17B6\u1793\u1794\u1789\u17D2\u1787\u17B6\u1780\u17CB\u1785\u17C6\u1793\u17BD\u1793\u1791\u17B9\u1780\u1794\u17D2\u179A\u17B6\u1780\u17CB\u1793\u17B9\u1784\u178F\u17D2\u179A\u17BC\u179C\u1785\u17C2\u1780\u179F\u17D2\u1798\u17BE\u17D7\u1782\u17D2\u1793\u17B6 /\n </span>\n <span>\n Note: If the percentage is not specified the amount will be shared equally\n </span>\n </p>\n </td>\n </tr>\n </table>\n <!-- table 5 existing insurance -->\n <table class=\"width-100 form-table\" style=\"margin-top:10px;\" cellpadding=\"10\">\n <colgroup>\n <col style=\"width: 60%;\" />\n <col style=\"width: 20%;\" />\n <col style=\"width: 20%;\" />\n </colgroup>\n <tr class=\"width-100\" cellpadding=\"10\">\n <td colspan=\"3\" style=\"text-align:center;\" class=\"text-lg font-bold\">\n <h5>\u179F\u17C1\u1785\u1780\u17D2\u178A\u17B8\u1794\u17D2\u179A\u1780\u17B6\u179F\u17A2\u17C6\u1796\u17B8\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u178A\u17C2\u179B\u1798\u17B6\u1793</h5>\n <h5>DECLARATION OF ANY EXISTING INSURANCE POLICIES</h5>\n </td>\n </tr>\n \n <tr>\n <td colspan=\"3\">\n <p class=\"mb-2\">\n <span>\n \u178F\u17BE\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u1798\u17B6\u1793\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u178A\u17C2\u179A\u17AC\u1791\u17C1 / Do you have any existing insurance policies?\n </span>\n <%- yesNoCheckbox(existing_insurance_info.has_existing_insurance) %>\n </p>\n <p class=\"mt-2\">\n <span>\n \u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17BE\u1798\u17B6\u1793 \u179F\u17BC\u1798\u1795\u17D2\u178A\u179B\u17CB\u1796\u17D0\u178F\u17CD\u1798\u17B6\u1793\u178A\u17BC\u1785\u1781\u17B6\u1784\u1780\u17D2\u179A\u17C4\u1798 / If yes, please provide the following information:\n <!-- <div class=\"form-field-line\"> -->\n </span>\n </p>\n </td>\n </tr>\n \n <tr>\n <td style=\"vertical-align: top;\">\n <p>\n \u1788\u17D2\u1798\u17C4\u17C7\u179A\u1794\u179F\u17CB\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\n </p>\n <p>\n Name of Insurance Company\n </p>\n </td>\n <td style=\"vertical-align: top;\">\n <p>\n \u1794\u17D2\u179A\u1797\u17C1\u1791\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u178A\u17C2\u179B\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u1798\u17B6\u1793\n </p>\n <p>\n Type of Policy You Currently Have\n </p>\n </td>\n <td style=\"vertical-align: top;\">\n <p>\n \u1791\u17B9\u1780\u1794\u17D2\u179A\u17B6\u1780\u17CB\u178F\u17D2\u179A\u17BC\u179C\u1794\u17B6\u1793\u1792\u17B6\u1793\u17B6\u179F\u179A\u17BB\u1794\n </p>\n <p>\n The Total Amount Insured (USD)\n </p>\n </td>\n </tr>\n \n <% existing_insurance_info.existing_policy_info.forEach(exist_pilicy=> { %>\n <tr>\n <td><b>\n <%= exist_pilicy.insurance_company %>\n </b></td>\n <td><b>\n <%= exist_pilicy.type_of_policy %>\n </b></td>\n <td><b>\n <%= exist_pilicy.sum_assured %>\n </b></td>\n </tr>\n <% }) %>\n \n <% if (existing_insurance_info.existing_policy_info.length===0) { %>\n <tr>\n <td class=\"height-25\">&nbsp;</td>\n <td>&nbsp;</td>\n <td>&nbsp;</td>\n </tr>\n <tr>\n <td class=\"height-25\">&nbsp;</td>\n <td>&nbsp;</td>\n <td>&nbsp;</td>\n </tr>\n <% } %>\n \n </tbody>\n </table>\n <!-- iMPORTANT Remark-->\n <h4 class=\"font-bold text-lg mt-5 underline\">\u1785\u17C6\u178E\u17B6\u17C6\u200B / IMPORTANT \u17D6</h4>\n \n <div class=\"my-2 space-y-2\">\n <p>\n \u1799\u17BE\u1784\u1781\u17D2\u1789\u17BB\u17C6\u179F\u17BC\u1798\u178E\u17C2\u1793\u17B6\u17C6\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u1798\u17B7\u1793\u1782\u17BD\u179A\u1795\u17D2\u179B\u17B6\u179F\u17CB\u1794\u17D2\u178F\u17BC\u179A\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u17A2\u17B6\u1799\u17BB\u1787\u17B8\u179C\u17B7\u178F\u178A\u17C2\u179B\u1798\u17B6\u1793\u179F\u17D2\u179A\u17B6\u1794\u17CB\u1787\u17B6\u1798\u17BD\u1799\u1793\u17B9\u1784\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u1790\u17D2\u1798\u17B8\u17D4\n \u1782\u17BB\u178E\u179C\u17B7\u1794\u178F\u17D2\u178F\u17B7\u1798\u17BD\u1799\u1785\u17C6\u1793\u17BD\u1793\u1782\u17BA\u17D6\n </p>\n <p>\n We advise you not to replace an existing life insurance policy with a new one. Some disadvantages are:\n </p>\n \n <ol style=\"list-style-type: decimal; padding-left: 30px; margin: 0;\">\n <li style=\"margin-bottom: 6px;\">\n \u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u17A2\u17B6\u1785\u1793\u17B9\u1784\u1798\u17B7\u1793\u1791\u1791\u17BD\u179B\u1794\u17B6\u1793\u1780\u17B6\u179A\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u178F\u17B6\u1798\u179B\u1780\u17D2\u1781\u1781\u178E\u17D2\u178C\u1791\u17BC\u1791\u17C5 /\n You may not be insurable on standard terms\n </li>\n \n <li style=\"margin-bottom: 6px;\">\n \u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u17A2\u17B6\u1785\u1793\u17B9\u1784\u178F\u17D2\u179A\u17BC\u179C\u1794\u1784\u17CB\u1794\u17BB\u1796\u17D2\u179C\u179B\u17B6\u1797\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u1781\u17D2\u1796\u179F\u17CB\u1787\u17B6\u1784\u1794\u1785\u17D2\u1785\u17BB\u1794\u17D2\u1794\u1793\u17D2\u1793\u178A\u17C4\u1799\u179F\u17B6\u179A\u1796\u17C1\u179B\u1793\u17C1\u17C7\u17A2\u17D2\u1793\u1780\u1798\u17B6\u1793\u17A2\u17B6\u1799\u17BB\u1785\u17D2\u179A\u17BE\u1793\u1787\u17B6\u1784\u1798\u17BB\u1793 /\n You may have to pay a higher premium as you are now older\n </li>\n \n <li>\n \u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u17A2\u17B6\u1785\u1793\u17B9\u1784\u1794\u17B6\u178F\u17CB\u1794\u1784\u17CB\u1780\u17C6\u178E\u17BE\u1793\u17A2\u178F\u17D2\u1790\u1794\u17D2\u179A\u1799\u17C4\u1787\u1793\u17CD\u17A0\u17B7\u179A\u1789\u17D2\u1789\u179C\u178F\u17D2\u1790\u17BB\u178A\u17C2\u179B\u1798\u17B6\u1793\u1780\u17D2\u1793\u17BB\u1784\u1786\u17D2\u1793\u17B6\u17C6\u1780\u1793\u17D2\u179B\u1784\u1798\u1780 /\n You may lose financial benefits built up over the years\n </li>\n </ol>\n <p>\n \u179F\u17BC\u1798\u1796\u17B7\u1782\u17D2\u179A\u17C4\u17C7\u1787\u17B6\u1798\u17BD\u1799\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u1794\u1785\u17D2\u1785\u17BB\u1794\u17D2\u1794\u1793\u17D2\u1793\u179A\u1794\u179F\u17CB\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780 \u1798\u17BB\u1793\u1793\u17B9\u1784\u1792\u17D2\u179C\u17BE\u1780\u17B6\u179A\u179F\u1798\u17D2\u179A\u17C1\u1785\u1785\u17B7\u178F\u17D2\u178F\u17D4\n \u179F\u17BC\u1798\u1792\u17D2\u179C\u17BE\u1780\u17B6\u179A\u1794\u17D2\u179A\u17C0\u1794\u1792\u17C0\u1794\u178A\u17C4\u1799\u1794\u17D2\u179A\u17BB\u1784\u1794\u17D2\u179A\u1799\u17D0\u178F\u17D2\u1793\u178A\u17BE\u1798\u17D2\u1794\u17B8\u1794\u17D2\u179A\u17B6\u1780\u178A\u1790\u17B6\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u1780\u17C6\u1796\u17BB\u1784\u1792\u17D2\u179C\u17BE\u1780\u17B6\u179A\n \u179F\u1798\u17D2\u179A\u17C1\u1785\u1785\u17B7\u178F\u17D2\u178F\u178A\u17C2\u179B\u179B\u17D2\u17A2\u1794\u17C6\u1795\u17BB\u178F\u179F\u1798\u17D2\u179A\u17B6\u1794\u17CB\u17A2\u178F\u17D2\u1790\u1794\u17D2\u179A\u1799\u17C4\u1787\u1793\u17CD\u179A\u1794\u179F\u17CB\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u17D4\n </p>\n <p>\n Please consult your current insurer before making a final decision. Make a careful comparison so that\n you\n can be sure you are making a decision that is in your best interest.\n </p>\n \n <p>\n \u178F\u17BE\u1798\u17B6\u1793\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u178E\u17B6\u1798\u17BD\u1799\u178A\u17C2\u179B\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u1780\u17C6\u1796\u17BB\u1784\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u178A\u17BE\u1798\u17D2\u1794\u17B8\u1787\u17C6\u1793\u17BD\u179F\n \u17AC\u1798\u17B6\u1793\u1794\u17C6\u178E\u1784\u1787\u17C6\u1793\u17BD\u179F\u178A\u17BC\u1785\u1794\u17B6\u1793\u179A\u17C0\u1794\u179A\u17B6\u1794\u17CB\u1781\u17B6\u1784\u179B\u17BE\u178A\u17C2\u179A\u17AC\u1791\u17C1?\n </p>\n <p>\n Is the insurance you are applying for to replace, or intended to replace, any of the policies listed\n above?\n </p>\n <%- yesNoCheckbox(existing_insurance_info.is_intended_to_replace) %>\n \n <p>\u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17BE\u1798\u17B6\u1793 \u1798\u17BD\u1799\u178E\u17B6? / If yes, which one?\n </p>\n \n <%- renderField(existing_insurance_info.replacement_detail_desc ) %>\n \n <p>\n <span>\u1799\u17BE\u1784\u1781\u17D2\u1789\u17BB\u17C6\u178F\u17D2\u179A\u17BC\u179C\u1780\u17B6\u179A\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u1793\u17C1\u17C7\u178A\u17BE\u1798\u17D2\u1794\u17B8\u1795\u17D2\u178F\u179B\u17CB\u178A\u17C6\u178E\u17B9\u1784\u178A\u179B\u17CB\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u1794\u1785\u17D2\u1785\u17BB\u1794\u17D2\u1794\u1793\u17D2\u1793\u179A\u1794\u179F\u17CB\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780(\u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17BE\u1798\u17B6\u1793)\u1790\u17B6\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u17A2\u17B6\u1785\u1793\u17B9\u1784\u179F\u1798\u17D2\u179A\u17C1\u1785\u1785\u17B7\u178F\u17D2\u178F\u1795\u17D2\u179B\u17B6\u179F\u17CB\u1794\u17D2\u178F\u17BC\u179A\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u17D4</span>\n <span>\n We need this information as we are required to inform your existing insurer-if you have one-that\n you\n may be\n replacing\n the policy.\n </span>\n </p>\n <span>\n \u178F\u17BE\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u1798\u17B6\u1793\u1780\u17B6\u179A\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\n \u17AC\u1796\u17B6\u1780\u17D2\u1799\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u1780\u17B6\u179A\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u17A2\u17B6\u1799\u17BB\u1787\u17B8\u179C\u17B7\u178F\u178E\u17B6\u1798\u17BD\u1799\u178A\u17C2\u179B\u178F\u17D2\u179A\u17BC\u179C\u1794\u17B6\u1793\u1794\u178A\u17B7\u179F\u17C1\u1792 \u1796\u1793\u17D2\u1799\u17B6\u179A\u1796\u17C1\u179B\n \u17AC\u1791\u1791\u17BD\u179B\u1799\u1780\u1780\u17D2\u179A\u17C4\u1798\u179B\u1780\u17D2\u1781\u1781\u178E\u17D2\u178C\u1796\u17B7\u179F\u17C1\u179F\u178A\u17C4\u1799\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u178E\u17B6\u1798\u17BD\u1799\u1795\u17D2\u179F\u17C1\u1784\u1791\u17C0\u178F\u178A\u17C2\u179A\u17AC\u1791\u17C1?\n \u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17BE\u1798\u17B6\u1793\u179F\u17BC\u1798\u1795\u17D2\u178F\u179B\u17CB\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u179B\u1798\u17D2\u17A2\u17B7\u178F\u178A\u17BC\u1785\u1781\u17B6\u1784\u1780\u17D2\u179A\u17C4\u1798\n </span>\n \n <%- yesNoCheckbox(existing_insurance_info.is_rejected_by_other_insurer) %>\n \n <p>\n Has any proposal or application for a Life Insurance policy of any kind ever been refused,\n postponed,\n or accepted at special terms by any other insurer? If yes, please provide details below:\n </p>\n </div>\n \n <table style=\"width:100%; table-layout:fixed; border-collapse:collapse;\" cellpadding=\"10\" class=\"form-table\">\n <colgroup>\n <col style=\"width: 25%;\" />\n <col style=\"width: 25%;\" />\n <col style=\"width: 25%;\" />\n <col style=\"width: 25%;\" />\n </colgroup>\n <tr>\n <td>\n <p>\u1788\u17D2\u1798\u17C4\u17C7\u179A\u1794\u179F\u17CB\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784</p>\n <p>Name of Insurance Company</p>\n </td>\n \n <td class=\"td-width-100\">\n <p>\n <b>\n <%= existing_insurance_info.rejected_insurance_company %>\n </b>\n </p>\n </td>\n \n <td>\n <p>\u1794\u17D2\u179A\u1797\u17C1\u1791\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784</p>\n <p>Type of Policy</p>\n </td>\n \n <td class=\"td-width-100\">\n <p>\n <b>\n <%= existing_insurance_info.rejected_policy_type %>\n </b>\n </p>\n </td>\n </tr>\n \n <tr>\n <td>\n <span>\u1798\u17BC\u179B\u17A0\u17C1\u178F\u17BB </span>\n <span>Reasons Given</span>\n </td>\n \n <td colspan=\"3\">\n <p>\n <b>\n <%= existing_insurance_info.rejected_reason %>\n </b>\n </p>\n </td>\n </tr>\n </table>\n <!-- page break -->\n <div style=\"page-break-after: always;\"></div>\n \n <!-- Part 7 Health Questions-->\n <table class=\"width-100 form-table\" style=\"margin-top:10px;\" cellpadding=\"10\">\n \n <tr class=\"width-100\" cellpadding=\"10\">\n <td colspan=\"3\" style=\"text-align:center;\" class=\"text-lg font-bold\">\n <h5>\u1795\u17D2\u1793\u17C2\u1780\u1791\u17B8\u17E4: \u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u1796\u17B6\u1780\u17CB\u1796\u17D0\u1793\u17D2\u1792\u1793\u17B9\u1784\u179F\u17BB\u1781\u1797\u17B6\u1796</h5>\n <h5>Part 4: HEALTH-RELATED QUESTIONS</h5>\n </td>\n </tr>\n \n <tr>\n <td style=\"width:35%;\" class=\"align-top\">\n <table style=\"border-collapse: collapse; width: 100%; border: none;\">\n <colgroup>\n <col style=\"width: 40%;\" />\n <col style=\"width: 60%;\" />\n </colgroup>\n <tr>\n <td style=\"white-space: nowrap; border: none;\">\n <span>\u1780\u1798\u17D2\u1796\u179F\u17CB / Height:</span>\n </td>\n <td style=\"border: none;\">\n <b>\n <u>\n <span class=\"font-eng font-bold\">\n <%= health_info.height %> \u179F.\u1798 / cm\n </span>\n </u>\n </b>\n </td>\n </tr>\n <tr>\n <td style=\"white-space: nowrap; border: none;\">\n <span>\u1791\u1798\u17D2\u1784\u1793\u17CB / Weight:</span>\n </td>\n <td style=\"border: none;\">\n <b><u>\n <span class=\"font-eng font-bold\">\n <%= health_info.weight %>\n </span>\n <span> \u1782.\u1780\u17D2\u179A / kg</span>\n </u></b>\n </td>\n </tr>\n </table>\n </td>\n \n <td class=\"align-top\">\n <p>\n <span>\n \u178F\u17BE\u1798\u17B6\u1793\u1780\u17B6\u179A\u1795\u17D2\u179B\u17B6\u179F\u17CB\u1794\u17D2\u178F\u17BC\u179A\u1791\u1798\u17D2\u1784\u1793\u17CB\u1780\u17D2\u1793\u17BB\u1784\u1780\u17C6\u17A1\u17BB\u1784\u1796\u17C1\u179B \u17E6 \u1781\u17C2\u17AC\u1791\u17C1? / Any weight changes during the past 6 month?\n </span>\n <%- yesNoCheckbox( health_info.is_weight_changed) %>\n </p>\n </td>\n </tr>\n \n <tr>\n <td class=\"align-top\">\n <p>\n \u178F\u17BE\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u1796\u17B7\u179F\u17B6\u179A\u1794\u17B6\u179A\u17B8\u178A\u17C2\u179A\u17AC\u1791\u17C1? / Do you smoke?\n </p>\n <%- yesNoCheckbox(health_info.is_smoke) %>\n </td>\n \n <td class=\"align-top\">\n <p>\n \u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17BE\u1798\u17B6\u1793 \u178F\u17BE\u1794\u17C9\u17BB\u1793\u17D2\u1798\u17B6\u1793\u178A\u17BE\u1798\u1780\u17D2\u1793\u17BB\u1784\u1798\u17BD\u1799\u1790\u17D2\u1784\u17C3? / If yes, How many cigarettes per day?\n </p>\n <%- renderField(health_info.smoke_detail) %>\n </td>\n </tr>\n \n <tr>\n <td class=\"align-top\">\n <p>\n Have you ever taken any kind of addictive substance/drugs?\n \u178F\u17BE\u17A2\u17D2\u1793\u1780\u1792\u17D2\u179B\u17B6\u1794\u17CB\u1794\u17D2\u179A\u17BE\u1794\u17D2\u179A\u17B6\u179F\u17CB\u179F\u17B6\u179A\u1792\u17B6\u178F\u17BB\u1789\u17C0\u1793 \u17AC\u1790\u17D2\u1793\u17B6\u17C6\u1789\u17C0\u1793\u178A\u17C2\u179A\u17AC\u1791\u17C1? /\n </p>\n <%- yesNoCheckbox(health_info.is_drug_or_substance) %>\n </td>\n \n <td class=\"align-top space-y-3\">\n <p>\n If yes, please state:\n \u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17BE\u1798\u17B6\u1793 \u179F\u17BC\u1798\u1794\u1789\u17D2\u1787\u17B6\u1780\u17CB\u178A\u17BC\u1785\u1781\u17B6\u1784\u1780\u17D2\u179A\u17C4\u1798 /\n </p>\n \n <p>\n <span>\n (\u1780). \u1794\u17D2\u179A\u1797\u17C1\u1791\u1790\u17D2\u1793\u17B6\u17C6 / Type of drug\n <%- renderField(health_info.drug_type) %>\n </span>\n </p>\n \n <p>\n <span>\n (\u1781). \u179A\u1799\u17C8\u1796\u17C1\u179B\u1794\u17D2\u179A\u17BE\u1794\u17D2\u179A\u17B6\u179F\u17CB / For how long?\n <%- renderField(health_info.drug_duration) %>\n </span>\n </p>\n \n <p>\n <span>\n (\u1782). \u178F\u17BE\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u1794\u17B6\u1793\u1788\u1794\u17CB\u1794\u17D2\u179A\u17BE\u1794\u17D2\u179A\u17B6\u179F\u17CB\u17A0\u17BE\u1799\u17AC\u1793\u17C5? / Have you stopped?\n <%- renderField(health_info.drug_stopped) %>\n </span>\n </p>\n \n </td>\n </tr>\n \n <tr>\n <td class=\"align-top\">\n <p>\n \u178F\u17BE\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u1796\u17B7\u179F\u17B6\u179A\u1782\u17D2\u179A\u17BF\u1784\u179F\u17D2\u179A\u179C\u17B9\u1784\u178A\u17C2\u179A\u17AC\u1791\u17C1? / Do you drink alcohol?\n </p>\n <%- yesNoCheckbox(health_info.is_alcohol) %>\n </td>\n \n <td>\n <p>\n \u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17BE\u1798\u17B6\u1793 \u178F\u17BE\u1789\u17B9\u1780\u1789\u17B6\u1794\u17CB\u178A\u17C2\u179A\u17AC\u1791\u17C1? / If yes, how often?\n </p>\n <p>\n \u179F\u17BC\u1798\u1794\u1789\u17D2\u1787\u17B6\u1780\u17CB\u1794\u179A\u17B7\u1798\u17B6\u178E\u178A\u17C2\u179B\u1794\u17B6\u1793\u1796\u17B7\u179F\u17B6\u179A\u1780\u17D2\u1793\u17BB\u1784\u1798\u17BD\u1799\u179F\u1794\u17D2\u178F\u17B6\u17A0\u17CD / Please specify amount of drink per week.\n <%- renderField(health_info.alcohol_detail) %>\n </p>\n </td>\n </tr>\n </table>\n <div class=\"space-y-2 my-3\">\n <p class=\"text-justify\">\u178F\u17BE\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u1798\u17B6\u1793\u17AA\u1796\u17BB\u1780\u1798\u17D2\u178F\u17B6\u1799 \u17AC\u1794\u1784\u1794\u17D2\u17A2\u17BC\u1793\u1794\u1784\u17D2\u1780\u17BE\u178F \u1798\u17B6\u1793\u1787\u17C6\u1784\u17BA \u17AC\u1791\u1791\u17BD\u179B\u1798\u179A\u178E\u1797\u17B6\u1796\u178A\u17C4\u1799\u179F\u17B6\u179A\u17D6 \u1787\u17C6\u1784\u17BA\u179C\u1784\u17D2\u179C\u17C1\u1784\n (Alzheimer's\n disease) \u1787\u17C6\u1784\u17BA\u1798\u17A0\u17B6\u179A\u17B8\u1780\n (Cancer) \u1787\u17C6\u1784\u17BA\u1787\u17B6\u179B\u17B7\u1780\u17B6\u1798\u17A0\u17B6\u179A\u17B8\u1780\u1798\u17B7\u1793\u1791\u17B6\u1793\u17CB\u179A\u17B6\u179B\u178A\u17B6\u179B (Carcinoma in situ) \u1787\u17C6\u1784\u17BA\u1795\u17D2\u179B\u17BC\u179C\u1785\u17B7\u178F\u17D2\u178F (Mental illness)\n \u1787\u17C6\u1784\u17BA\u1791\u17B9\u1780\u1793\u17C4\u1798\u1795\u17D2\u17A2\u17C2\u1798\n (Diabetes) \u1787\u17C6\u1784\u17BA\u178F\u1798\u17D2\u179A\u1784\u1793\u17C4\u1798 (polycystic kidney disease) \u1787\u17C6\u1784\u17BA\u178A\u17B6\u1785\u17CB\u179F\u179A\u179F\u17C3\u1788\u17B6\u1798\u1781\u17BD\u179A\u1780\u17D2\u1794\u17B6\u179B (Stroke)\n \u1780\u17B6\u179A\u17A1\u17BE\u1784\u179F\u1798\u17D2\u1796\u17B6\u1792\u1788\u17B6\u1798\u1781\u17D2\u1796\u179F\u17CB\n (High\n blood pressure) \u1787\u17C6\u1784\u17BA\u1794\u17C1\u17C7\u178A\u17BC\u1784 (Heart Disease) \u17AC\u1787\u17C6\u1784\u17BA\u178F\u17C6\u178E\u1796\u17BC\u1787\u178A\u1791\u17C3\u1791\u17C0\u178F (Hereditary disease) \u178A\u17C2\u179A\u17AC\u1791\u17C1?</p>\n \n <p class=\"text-justify\">Have any of your biological parents or siblings been diagnosed with or passed\n away as\n a\n result\n of: Alzheimer's\n disease, cancer, carcinoma in situ, mental illness, diabetes, polycystic kidney disease, stroke, high\n blood\n pressure, heart disease, or any other hereditary disease?</p>\n \n <%- yesNoCheckbox(health_info.is_hereditary_disease) %>\n \n <p class=\"mb-3\">\u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17BE\u1798\u17B6\u1793 \u179F\u17BC\u1798\u1795\u17D2\u178A\u179B\u17CB\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u179B\u1798\u17D2\u17A2\u17B7\u178F\u178A\u17BC\u1785\u1781\u17B6\u1784\u1780\u17D2\u179A\u17C4\u1798 / If yes, please provide details below:\n </p>\n </div>\n \n <table style=\"width:100%; table-layout:fixed; border-collapse:collapse;\" cellpadding=\"10\" class=\"form-table\">\n <colgroup>\n <col style=\"width: 25%;\" />\n <col style=\"width: 25%;\" />\n <col style=\"width: 25%;\" />\n <col style=\"width: 25%;\" />\n </colgroup>\n <tr>\n <td>\n <p>\u1788\u17D2\u1798\u17C4\u17C7\u179A\u1794\u179F\u17CB\u179F\u17B6\u1785\u17CB\u1789\u17B6\u178F\u17B7</p>\n <p>Name of Relative</p>\n </td>\n \n <td>\n <p>\u1791\u17C6\u1793\u17B6\u1780\u17CB\u1791\u17C6\u1793\u1784\u1787\u17B6\u1798\u17BD\u1799\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780</p>\n <p>Relationship to you</p>\n </td>\n \n <td>\n <p>\u1787\u1798\u17D2\u1784\u17BA</p>\n <p>Illness</p>\n </td>\n \n <td>\n <p>\u179A\u179F\u17CB\u1793\u17C5 \u17AC\u1791\u1791\u17BD\u179B\u1798\u179A\u178E\u17C8\u1797\u17B6\u1796</p>\n <p>Living or Deceased?</p>\n </td>\n </tr>\n \n <% health_info.hereditary_relative_info.forEach(hereditary=> { %>\n <tr>\n <td><b>\n <%= hereditary.full_name %>\n </b></td>\n <td><b>\n <%= hereditary.relationship %>\n </b></td>\n <td><b>\n <%= hereditary.illness %>\n </b></td>\n <td><b>\n <%= hereditary.living_or_deceased %>\n </b></td>\n </tr>\n <% }) %>\n \n <% if (health_info.hereditary_relative_info.length===0) { %>\n <tr>\n <td class=\"height-25\">&nbsp;</td>\n <td>&nbsp;</td>\n <td>&nbsp;</td>\n <td>&nbsp;</td>\n </tr>\n <% } %>\n </table>\n </div>\n \n <div id=\"questions-source\">\n <!-- Additional Questions-->\n <table class=\"table w-full table-fixed border-collapse form-table\" cellpadding=\"10\">\n \n <colgroup>\n <col style=\"width: 45%;\" />\n <col style=\"width: 10%;\" />\n <col style=\"width: 10%;\" />\n <col style=\"width: 35%;\" />\n </colgroup>\n \n <!-- Header -->\n <tr class=\"width-100\" cellpadding=\"10\">\n <td colspan=\"4\" style=\"text-align:center;\" class=\"text-lg font-bold\">\n <h5>\u179F\u17C6\u178E\u17BD\u179A\u1794\u1793\u17D2\u1790\u17C2\u1798</h5>\n <h5>ADDITIONAL QUESTIONS</h5>\n </td>\n </tr>\n \n <!-- Sub-header -->\n <tr>\n <td rowspan=\"2\" class=\"align-top\">\n <p>\n 1.\u178F\u17BE\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u1792\u17D2\u179B\u17B6\u1794\u17CB\u1794\u17B6\u1793\u1791\u1791\u17BD\u179B\u1780\u17B6\u179A\u1796\u17D2\u1799\u17B6\u1794\u17B6\u179B\u1787\u17C6\u1784\u17BA \u17AC\u1798\u17B6\u1793\u179A\u17C4\u1782\u179F\u1789\u17D2\u1789\u17B6\u178E\u1798\u17BD\u1799\u178A\u17BC\u1785\u1781\u17B6\u1784\u1780\u17D2\u179A\u17C4\u1798\u178A\u17C2\u179A\u17AC\u1791\u17C1?\n </p>\n <p>\n Have you ever had or treated for any of the following conditions or symptoms?\n </p>\n </td>\n <td colspan=\"2\" class=\"text-center align-top\">\n <span>\u179F\u17BC\u1798\u1782\u17BC\u179F / Please Tick</span>\n </td>\n <td rowspan=\"2\" class=\"align-top\">\n <p>\n \u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17BE\u1798\u17B6\u1793 \u179F\u17BC\u1798\u1795\u17D2\u178F\u179B\u17CB\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u179B\u1798\u17D2\u17A2\u17B7\u178F\u1781\u17B6\u1784\u1780\u17D2\u179A\u17C4\u1798\n </p>\n <p>\n If yes, please provide more details:\n </p>\n </td>\n </tr>\n \n <!-- Question 1 -->\n <tr>\n <td style=\"width:10%; text-align: center; vertical-align: middle;\">\n <p>\u1798\u17B6\u1793 / Yes</p>\n </td>\n <td style=\"width:10%; text-align: center; vertical-align: middle;\">\n <p>\u1798\u17B7\u1793\u1798\u17B6\u1793 / No</p>\n </td>\n </tr>\n \n <% const additionalQuestions=health_info.additional_question_info; const questionNumbers=Array.from({ length: 17 },\n (_, i)=> i + 2); // q2 - q18\n %>\n \n <% questionNumbers.forEach(num=> { %>\n <tr class=\"question-row\">\n <td class=\"align-top space-y-2 text-justify\">\n <p>\n <%= num %>.\n <%= additionalQuestions['q' + num + '_question_kh'] %>\n </p>\n <p class=\"text-justify\">\n <%= additionalQuestions['q' + num + '_question_en'] %>\n </p>\n </td>\n \n <td style=\"text-align:center; vertical-align:middle;\">\n <%- renderCheck(additionalQuestions['q' + num], true) %>\n </td>\n \n <td style=\"text-align:center; vertical-align:middle;\">\n <%- renderCheck(additionalQuestions['q' + num], false) %>\n </td>\n <td class=\"text-justify align-top\">\n <div>\n <p>\n <%= additionalQuestions['q' + num + '_detail'] || '' %>\n </p>\n </div>\n </td>\n </tr>\n <% }) %>\n </table>\n \n <div class=\"question-row declaration-header\">\n <table class=\"table w-full table-fixed border-collapse form-table\" cellpadding=\"20\">\n <tr>\n <td colspan=\"4\" style=\"text-align:center;\" class=\"text-lg font-bold\">\n <h5>\u179F\u17C1\u1785\u1780\u17D2\u178F\u17B8\u1794\u17D2\u179A\u1780\u17B6\u179F\u179A\u1794\u179F\u17CB\u17A2\u17D2\u1793\u1780\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6</h5>\n <h5>DECLARATION BY THE APPLICANT</h5>\n </td>\n </tr>\n </table>\n \n <!-- Declaration by the application-->\n <div class=\"mt-5 space-y-3 text-justify\">\n <p>\u1781\u17D2\u179B\u17B9\u1798\u179F\u17B6\u179A\u1793\u17C3\u1796\u17B6\u1780\u17D2\u1799\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u1793\u17C1\u17C7\u178F\u17D2\u179A\u17BC\u179C\u1794\u17B6\u1793\u1796\u1793\u17D2\u1799\u179B\u17CB\u1799\u17C9\u17B6\u1784\u1785\u17D2\u1794\u17B6\u179F\u17CB\u17A0\u17BE\u1799\u1781\u17D2\u1789\u17BB\u17C6\u1794\u17B6\u1793\u1799\u179B\u17CB\u1791\u17B6\u17C6\u1784\u179F\u17D2\u179A\u17BB\u1784\u17D4\u200B</p>\n <p>The contents of this application have been explained to me, and I have fully understood them. </p>\n <p>\n \u1781\u17D2\u1789\u17BB\u17C6\u179F\u17BC\u1798\u1794\u1789\u17D2\u1787\u17B6\u1780\u17CB\u1790\u17B6\n \u1785\u1798\u17D2\u179B\u17BE\u1799\u178A\u17C2\u179B\u1795\u17D2\u178F\u179B\u17CB\u1787\u17BC\u1793\u1793\u17C5\u1780\u17D2\u1793\u17BB\u1784\u17AF\u1780\u179F\u17B6\u179A\u1793\u17C1\u17C7\u1796\u17B7\u178F\u1787\u17B6\u178F\u17D2\u179A\u17B9\u1798\u178F\u17D2\u179A\u17BC\u179C\u1791\u17C4\u17C7\u1794\u17B8\u1787\u17B6\u178F\u17D2\u179A\u17BC\u179C\u1794\u17B6\u1793\u1794\u17C6\u1796\u17C1\u1789\u178A\u17C4\u1799\u1781\u17D2\u1789\u17BB\u17C6\u17AC\u178A\u17C4\u1799\u17A2\u17D2\u1793\u1780\u1795\u17D2\u179F\u17C1\u1784\u1791\u17C0\u178F\u1780\u17D2\u1793\u17BB\u1784\u1793\u17B6\u1798\n \u179A\u1794\u179F\u17CB\u1781\u17D2\u1789\u17BB\u17C6\u1780\u17CF\u178A\u17C4\u1799\u1781\u17D2\u1789\u17BB\u17C6\u1791\u1791\u17BD\u179B\u1781\u17BB\u179F\u178F\u17D2\u179A\u17BC\u179C\u1791\u17B6\u17C6\u1784\u179F\u17D2\u179A\u17BB\u1784\u1785\u17C6\u1796\u17C4\u17C7\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u1791\u17B6\u17C6\u1784\u1793\u17C4\u17C7\u17A0\u17BE\u1799\u1781\u17D2\u1789\u17BB\u17C6\u1798\u17B7\u1793\u1794\u17B6\u1793\u179B\u17B6\u1780\u17CB\u1794\u17B6\u17C6\u1784\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u17A2\u17D2\u179C\u17B8\u1791\u17B6\u17C6\u1784\u17A2\u179F\u17CB\u17D4\n </p>\n <p>\n I confirm that the answers provided in this\n document are true, and whether written by me or anyone else on my behalf I\n accept full responsibility for them, and that I have not withheld any material\n information.\n </p>\n <p>\n \u1781\u17D2\u1789\u17BB\u17C6\u1799\u179B\u17CB\u179F\u17D2\u179A\u1794\u1790\u17B6\u1793\u17B9\u1784\u1798\u17B7\u1793\u1798\u17B6\u1793\u1780\u17B6\u179A\u1791\u1791\u17BD\u179B\u1781\u17BB\u179F\u178F\u17D2\u179A\u17BC\u179C\u178E\u17B6\u1798\u17BD\u1799\u1796\u17B8\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793\n <span class=\"font-bold text-lg\">\u17A0\u17D2\u179C\u17B8\u179B\u17B8\u1796 \u17A1\u17B6\u1799\u17A0\u17D2\u179C\u17CD \u17A2\u17B6\u179F\u17BD\u179A\u17C1\u1793 (\u1781\u17C1\u1798\u1794\u17BC\u178C\u17B6) \u1798.\u1780 </span>\n \u179A\u17A0\u17BC\u178F\u1791\u17B6\u179B\u17CB\u178F\u17C2\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\n \u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u1793\u17C1\u17C7\u178F\u17D2\u179A\u17BC\u179C\u1794\u17B6\u1793\u1785\u17C1\u1789\u1793\u17B7\u1784\u1794\u17D2\u179A\u1782\u179B\u17CB\u1787\u17BC\u1793\u1781\u17D2\u1789\u17BB\u17C6\u17A0\u17BE\u1799\u1794\u17BB\u1796\u17D2\u179C\u179B\u17B6\u1797\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u178A\u17C6\u1794\u17BC\u1784\u1794\u17B6\u1793\u1794\u1784\u17CB\u17D4\u179A\u17B6\u179B\u17CB\u1780\u17B6\u179A\u1791\u17BC\u1791\u17B6\u178F\u17CB\u1794\u17BB\u1796\u17D2\u179C\u179B\u17B6\u1797\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u1791\u17C5\u17B2\u17D2\u1799\u1798\u17D2\u1785\u17B6\u179F\u17CB\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\n \u17AC\u17A2\u17D2\u1793\u1780\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u1793\u17B9\u1784\u178F\u17D2\u179A\u17BC\u179C\u1792\u17D2\u179C\u17BE\u17A1\u17BE\u1784\u178F\u17B6\u1798\u179A\u1799\u17C8\u17AF\u1780\u179F\u17B6\u179A\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u1792\u1793\u17B6\u1782\u17B6\u179A\u178A\u17C2\u179B\u1794\u17B6\u1793\u1797\u17D2\u1787\u17B6\u1794\u17CB\u1780\u17D2\u1793\u17BB\u1784\u17A2\u17C6\u17A1\u17BB\u1784\u1796\u17C1\u179B\n \u178A\u17B6\u1780\u17CB\u1796\u17B6\u1780\u17D2\u1799\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u1793\u17C1\u17C7\u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17BE\u1782\u17D2\u1798\u17B6\u1793\u1780\u17B6\u179A\u1795\u17D2\u178A\u179B\u17CB\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u1792\u1793\u17B6\u1782\u17B6\u179A\u1790\u17D2\u1798\u17B8\u178E\u17B6\u1798\u17BD\u1799\u1798\u1780\u1780\u17B6\u1793\u17CB\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793\u17D4\n </p>\n </p>\n <p>I agree that there shall be no liability upon\n <span class=\"font-bold text-lg\">Phillip Life Assurance (Cambodia) Plc</span>. until a policy has\n been issued and\n delivered to me and the first premium is paid in full. All premium to be refunded to Policyholders\n or Applicants will\n be made through the bank information given\n during an application process, if no latest bank information has been provided and received by the\n company.\n </p>\n <p>\n \u1781\u17D2\u1789\u17BB\u17C6\u1799\u179B\u17CB\u1796\u17D2\u179A\u1798 \u1793\u17B7\u1784\u1795\u17D2\u178F\u179B\u17CB\u179F\u17B7\u1791\u17D2\u1792\u17B7\u17B2\u17D2\u1799\u179F\u17D2\u1790\u17B6\u1794\u17D0\u1793\u179C\u17C1\u1787\u17D2\u1787\u179F\u17B6\u179F\u17D2\u178F\u17D2\u179A\n \u1780\u17B6\u179A\u17B7\u1799\u17B6\u179B\u17D0\u1799\u179A\u1794\u179F\u17CB\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\n \u17AC\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u17A2\u17B6\u1799\u17BB\u1787\u17B8\u179C\u17B7\u178F\u178A\u1791\u17C3\u1791\u17C0\u178F \u178A\u17BE\u1798\u17D2\u1794\u17B8\u1794\u17D2\u179A\u1782\u179B\u17CB\u1791\u17C5\u17B2\u17D2\u1799\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\n <span class=\"font-bold text-lg\">\u17A0\u17D2\u179C\u17B8\u179B\u17B8\u1796 \u17A1\u17B6\u1799\u17A0\u17D2\u179C\u17CD \u17A2\u17B6\u179F\u17BD\u179A\u17C1\u1793 (\u1781\u17C1\u1798\u1794\u17BC\u178C\u17B6) \u1798.\u1780</span>\n \u1793\u17BC\u179C\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u1791\u17B6\u1780\u17CB\u1791\u1784\u1793\u17B9\u1784\u1781\u17D2\u1789\u17BB\u17C6\n \u1782\u17D2\u179A\u1794\u17CB\u1796\u17C1\u179B\u178A\u17C4\u1799\u1798\u17B7\u1793\u1782\u17B7\u178F\u1796\u17B8\u179B\u1791\u17D2\u1792\u1795\u179B\u1793\u17C3\u1796\u17B6\u1780\u17D2\u1799\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u179A\u1794\u179F\u17CB\u1781\u17D2\u1789\u17BB\u17C6\u17A1\u17BE\u1799\u17D4\n </p>\n <p>And I also agree and authorise (a) any\n medical source, insurance office, or other Life Insurance company to release to\n <span class=\"font-bold text-lg\">Phillip Life Assurance (Cambodia) Plc.</span> any relevant\n information concerning me\n at\n any time, regardless of the outcome of my application.\n </p>\n <p>\n \u1781\u17D2\u1789\u17BB\u17C6\u17A2\u1793\u17BB\u1789\u17D2\u1789\u17B6\u178F \u1793\u17B7\u1784\u1799\u179B\u17CB\u1796\u17D2\u179A\u1798\u17B2\u17D2\u1799\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793\u1794\u17D2\u179A\u17BE\u1794\u17D2\u179A\u17B6\u179F\u17CB\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u200B\n \u1793\u17B7\u1784\u1791\u17B7\u1793\u17D2\u1793\u1793\u17D0\u1799\u1791\u17B6\u17C6\u1784\u179F\u17D2\u179A\u17BB\u1784\u178A\u17C2\u179B\u1781\u17D2\u1789\u17BB\u17C6\u1794\u17B6\u1793\u1795\u17D2\u178A\u179B\u17CB\u1793\u17C5\u1780\u17D2\u1793\u17BB\u1784\u1796\u17B6\u1780\u17D2\u1799\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u179A\u1794\u179F\u17CB\u1781\u17D2\u1789\u17BB\u17C6\n \u1780\u17D2\u1793\u17BB\u1784\u1782\u17C4\u179B\u1794\u17C6\u178E\u1784\u179F\u17D2\u179A\u1794\u178F\u17B6\u1798\u1785\u17D2\u1794\u17B6\u1794\u17CB\u178A\u17BC\u1785\u1787\u17B6\u1780\u17B6\u179A\u1795\u17D2\u179F\u1796\u17D2\u179C\u1795\u17D2\u179F\u17B6\u1799\u1791\u17B8\u1795\u17D2\u179F\u17B6\u179A \u1780\u17B6\u179A\u179F\u17B7\u1780\u17D2\u179F\u17B6\u1791\u17B8\u1795\u17D2\u179F\u17B6\u179A \u1793\u17B7\u1784\u1780\u17B6\u179A\u1794\u1798\u17D2\u179A\u17BE\u17A2\u178F\u17B7\u1790\u17B7\u1787\u1793\u178A\u17C4\u1799\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793\n \u179F\u1798\u17D2\u1796\u17D0\u1793\u17D2\u1792\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793 \u17AC\u1787\u17B6\u178A\u17C3\u1782\u17BC\u1796\u17B6\u178E\u17B7\u1787\u17D2\u1787\u1780\u1798\u17D2\u1798\u179A\u1794\u179F\u17CB\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793\u178A\u17C4\u1799\u1798\u17B7\u1793\u1785\u17B6\u17C6\u1794\u17B6\u1785\u17CB\u1798\u17B6\u1793\u1780\u17B6\u179A\u1799\u179B\u17CB\u1796\u17D2\u179A\u1798\n \u1793\u17B7\u1784\u1787\u17BC\u1793\u178A\u17C6\u178E\u17B9\u1784\u1794\u1793\u17D2\u1790\u17C2\u1798\u1796\u17B8\u1781\u17D2\u1789\u17BB\u17C6\u17A1\u17BE\u1799\u17D4\n \u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793\u1798\u17B7\u1793\u178F\u17D2\u179A\u17BC\u179C\u1794\u17B6\u1793\u17A2\u1793\u17BB\u1789\u17D2\u1789\u17B6\u178F\u17B2\u17D2\u1799\u1794\u1789\u17D2\u1785\u17C1\u1789\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u178E\u17B6\u1798\u17BD\u1799\u1791\u17C5\u1797\u17B6\u1782\u17B8\u1791\u17B8\u1794\u17B8\u178E\u17B6\u1798\u17BD\u1799\u17AC\u1794\u17D2\u179A\u17BE\u1794\u17D2\u179A\u17B6\u179F\u17CB\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u1793\u17C4\u17C7\u179F\u1798\u17D2\u179A\u17B6\u1794\u17CB\u1782\u17C4\u179B\u1794\u17C6\u178E\u1784\u1795\u17D2\u179F\u17C1\u1784\u1791\u17C0\u178F\u178A\u17C2\u179B\u1798\u17B7\u1793\u1791\u17B6\u1780\u17CB\u1791\u1784\u1793\u17B9\u1784\u1782\u17C4\u179B\u1794\u17C6\u178E\u1784\u1791\u17B6\u17C6\u1784\u17A1\u17B6\u1799\u1781\u17B6\u1784\u179B\u17BE\u17A1\u17BE\u1799\n \u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17BE\u1782\u17D2\u1798\u17B6\u1793\u1780\u17B6\u179A\u1799\u179B\u17CB\u1796\u17D2\u179A\u1798\u1796\u17D2\u179A\u17C0\u1784\u1787\u17B6\u179B\u17B6\u1799\u179B\u1780\u17D2\u1781\u178E\u17CD\u17A2\u1780\u17D2\u179F\u179A\u1793\u17C4\u17C7\u17D4\n </p>\n <p style=\"margin-bottom:5px\">\n I authorize and consent the Company to use all of my information provided in my application form\n in legal purpose such as marketing, market survey and customer service by company, affiliate,\n or business partner without my prior consent or notification. The Company shall not allow to\n disclose any information of any other purpose not related to above mentioned purpose without prior\n consent in written.\n </p>\n </div>\n </div>\n \n <div class=\"question-row declaration-header\">\n <table class=\"width-100 form-table\" style=\"margin-top: 10px;\" cellpadding=\"15\">\n <tbody>\n <tr class=\"text-start-top\">\n <!-- Policyholder -->\n <td width=\"50%\">\n <div style=\"\n display: flex;\n flex-direction: column;\n justify-content: space-between;\n min-height: 250px;\n text-align: left; /* change to left */\n \">\n <div>\n <p style=\"margin:0;\">\n \u17A0\u178F\u17D2\u1790\u179B\u17C1\u1781\u17B6 \u17AC\u179F\u17D2\u1793\u17B6\u1798\u1798\u17C1\u178A\u17C3\u179A\u1794\u179F\u17CB\u1798\u17D2\u1785\u17B6\u179F\u17CB\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\n </p>\n <p style=\"margin:0;\">\n Signature or thumb print of Policyholder\n </p>\n </div>\n <div class=\"flex items-center gap-2 w-full\">\n <span>\u17A0\u178F\u17D2\u1790\u179B\u17C1\u1781\u17B6 \u17AC\u179F\u17D2\u1793\u17B6\u1798\u1798\u17C1\u178A\u17C3 / Signature or thumb print</span>\n \n <div class=\"flex-1 border-b border-black min-h-[18px] mt-1\"></div>\n </div>\n </div>\n </td>\n \n <!-- Life assured -->\n <td width=\"50%\">\n <div class=\"flex flex-col justify-between min-h-[250px] text-left\">\n <div>\n <p style=\"margin:0;\">\n \u17A0\u178F\u17D2\u1790\u179B\u17C1\u1781\u17B6 \u17AC\u179F\u17D2\u1793\u17B6\u1798\u1798\u17C1\u178A\u17C3\u179A\u1794\u179F\u17CB\u17A2\u17D2\u1793\u1780\u178F\u17D2\u179A\u17BC\u179C\u1794\u17B6\u1793\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\n (\u17A0\u178F\u17D2\u1790\u179B\u17C1\u1781\u17B6\u179A\u1794\u179F\u17CB\u17AA\u1796\u17BB\u1780\u1798\u17D2\u178F\u17B6\u1799 \u17AC\u17A2\u17B6\u178E\u17B6\u1796\u17D2\u1799\u17B6\u1794\u17B6\u179B\u179F\u17D2\u179A\u1794\u1785\u17D2\u1794\u17B6\u1794\u17CB \u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17BE\u17A2\u17D2\u1793\u1780\n \u178F\u17D2\u179A\u17BC\u179C\u1794\u17B6\u1793\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u1798\u17B6\u1793\u17A2\u17B6\u1799\u17BB\u1780\u17D2\u179A\u17C4\u1798 \u17E1\u17E8 \u1786\u17D2\u1793\u17B6\u17C6)\n </p>\n <p style=\"margin:0;\">\n Signature or thumb print of Life assured (Parent or the legal guardian's signature if the\n Life assured is less than 18\n years old)\n </p>\n </div>\n <div class=\"flex items-center gap-2 w-full\">\n <span>\u17A0\u178F\u17D2\u1790\u179B\u17C1\u1781\u17B6 \u17AC\u179F\u17D2\u1793\u17B6\u1798\u1798\u17C1\u178A\u17C3 / Signature or thumb print</span>\n \n <div class=\"flex-1 border-b border-black min-h-[18px] mt-1\"></div>\n </div>\n </div>\n </td>\n </tr>\n <!-- Names -->\n <tr>\n <td style=\"text-align: start; padding-top: 10px;\">\n <span>\u1788\u17D2\u1798\u17C4\u17C7</span>\n <span>/ Name:</span>\n <span style=\"font-weight: bold;\">\n <%= signature_info.ph_full_name %>\n </span>\n <!-- <span style=\"text-transform: uppercase; font-weight: bold;\">SOK CHANTHA</span> -->\n </td>\n <td style=\"text-align: start; padding-top: 10px;\">\n <span>\u1788\u17D2\u1798\u17C4\u17C7</span>\n <span>/ Name:</span>\n <span style=\"font-weight: bold;\">\n <%= signature_info.la_full_name %>\n </span>\n <!-- <span style=\"font-weight: bold;\">PHAN DARA</span> -->\n </td>\n </tr>\n <!-- Dates -->\n <tr>\n <td style=\"text-align: start; padding-top: 10px;\">\n <span>\u1780\u17B6\u179B\u1794\u179A\u17B7\u1785\u17D2\u1786\u17C1\u1791</span>\n <span>\n Date:\n <%- signature_info.ph_signature_date ? '<u><b>' + signature_info.ph_signature_date + '</b></u>'\n : '<span style=\"display:inline-block; width:120px; border-bottom:1px solid #000; min-height:18px;\"></span>'\n %>\n </span>\n </td>\n <td style=\"text-align: start; padding-top: 10px;\">\n <span>\u1780\u17B6\u179B\u1794\u179A\u17B7\u1785\u17D2\u1786\u17C1\u1791</span>\n <span>\n Date:\n <%- signature_info.la_signature_date ? '<u><b>' + signature_info.la_signature_date + '</b></u>'\n : '<span style=\"display:inline-block; width:120px; border-bottom:1px solid #000; min-height:18px;\"></span>'\n %>\n </span>\n </td>\n </tr>\n </tbody>\n </table>\n </div>\n \n <div class=\"question-row declaration-header\">\n <table class=\"form-table w-full table-fixed mt-2\" cellpadding=\"15\">\n <!-- Signature line -->\n <tr>\n <td style=\"height: 50px; vertical-align: center; text-align: start;\">\n <p>\n <span>\n \u17A0\u178F\u17D2\u1790\u179B\u17C1\u1781\u17B6 \u17AC\u179F\u17D2\u1793\u17B6\u1798\u1798\u17C1\u178A\u17C3\u179A\u1794\u179F\u17CB\u1791\u17B8\u1794\u17D2\u179A\u17B9\u1780\u17D2\u179F\u17B6\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784 \u17AC\u179F\u17B6\u1780\u17D2\u179F\u17B8\n </span>\n <span>\n (Signature or thumb print of Advisor/witness)\n </span>\n <br>\n <div class=\"flex-1 border-b border-black min-h-[50px] mt-1\"></div>\n </p>\n </td>\n </tr>\n <!-- Name -->\n <tr>\n <td style=\"text-align: start; vertical-align: center; padding-top: 5px;\">\n <span>\u1788\u17D2\u1798\u17C4\u17C7</span>\n <span>\n Name:\n <%- signature_info.agent_full_name ? '<u><b>' + signature_info.agent_full_name+ '</b></u>'\n : '<span style=\"display:inline-block; width:120px; border-bottom:1px solid #000; min-height:18px;\"></span>'\n %>\n </span>\n </td>\n </tr>\n <!-- Date -->\n <tr>\n <td style=\"text-align: start; vertical-align: center; padding-top: 5px;\">\n <span>\u1780\u17B6\u179B\u1794\u179A\u17B7\u1785\u17D2\u1786\u17C1\u1791</span>\n <span>\n Date:\n <%- signature_info.agent_signature_date ? '<u><b>' + signature_info.agent_signature_date+ '</b></u>'\n : '<span style=\"display:inline-block; width:120px; border-bottom:1px solid #000; min-height:18px;\"></span>'\n %>\n </span>\n </td>\n </tr>\n </table>\n </div>\n \n <div class=\"question-row declaration-header\">\n <table style=\"margin-top: 10px;\" class=\"width-100 form-table\" cellpadding=\"15\">\n <tbody class=\"width-100\">\n <!-- Title -->\n <tr class=\"width-100\" cellpadding=\"10\">\n <td colspan=\"3\" style=\"text-align:center;\" class=\"text-lg font-bold\">\n <h5>\u1780\u17B6\u179A\u1794\u1789\u17D2\u1787\u17B6\u1780\u17CB\u178A\u17C4\u1799\u17A2\u17D2\u1793\u1780\u178F\u17C6\u178E\u17B6\u1784 \u17A0\u17D2\u179C\u17B8\u179B\u17B8\u1796 \u17A1\u17B6\u1799\u17A0\u17D2\u179C\u17CD \u17A2\u17B6\u179F\u17BD\u179A\u17C1\u1793 (\u1781\u17C1\u1798\u1794\u17BC\u178C\u17B6) \u1798.\u1780</h5>\n <h5>Phillip Life Assurance (Cambodia) Plc Representative Certification</h5>\n </td>\n </tr>\n <!-- Content -->\n <tr>\n <td style=\"text-align: start;\">\n <p>\n \u1781\u17D2\u1789\u17BB\u17C6\u1794\u17B6\u1793\u1787\u17BD\u1794\u17A2\u17D2\u1793\u1780\u178A\u17B6\u1780\u17CB\u1796\u17B6\u1780\u17D2\u1799\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6 \u1793\u17B7\u1784\u17A2\u17D2\u1793\u1780\u178A\u17C2\u179B\u1793\u17B9\u1784\u178F\u17D2\u179A\u17BC\u179C\u1794\u17B6\u1793\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u178A\u17C4\u1799\u1795\u17D2\u1791\u17B6\u179B\u17CB\n \u1793\u17B7\u1784\u1794\u17B6\u1793\u1796\u1793\u17D2\u1799\u179B\u17CB\u17A2\u17C6\u1796\u17B8 \u1781 \u1793\u17B7\u1784\u179B\u1780\u17D2\u1781\u1781\u178E\u17D2\u178C\u1793\u17C3\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u178A\u179B\u17CB\u17A2\u17D2\u1793\u1780\u178A\u17B6\u1780\u17CB\u1796\u17B6\u1780\u17D2\u1799\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u17D4\n </p>\n \n <p>\n \u1781\u17D2\u1789\u17BB\u17C6\u1794\u17B6\u1793\u1783\u17BE\u1789\u17A2\u178F\u17D2\u178F\u179F\u1789\u17D2\u1789\u17B6\u178E\u1794\u17D0\u178E\u17D2\u178E\u179A\u1794\u179F\u17CB\u17A2\u17D2\u1793\u1780\u178A\u17B6\u1780\u17CB\u1796\u17B6\u1780\u17D2\u1799\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6 \u1793\u17B7\u1784\u1794\u17B6\u1793\u1790\u178F\u1785\u17C6\u179B\u1784\u178F\u17D2\u179A\u17B9\u1798\u178F\u17D2\u179A\u17BC\u179C\u178F\u17B6\u1798\u1785\u17D2\u1794\u17B6\u1794\u17CB\u178A\u17BE\u1798\u17D4\n \u1781\u17D2\u1789\u17BB\u17C6\u179F\u17BC\u1798\u1794\u1789\u17D2\u1787\u17B6\u1780\u17CB\u1790\u17B6\u179B\u17C1\u1781\u17A2\u178F\u17D2\u178F\u179F\u1789\u17D2\u1789\u17B6\u178E\u1794\u17D0\u178E\u17D2\u178E\u179A\u1794\u179F\u17CB\u17A2\u17D2\u1793\u1780\u178A\u17B6\u1780\u17CB\u1796\u17B6\u1780\u17D2\u1799\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u1782\u17BA\n <u><b>\n <%= rep_certification_info.identifier_no %>\n </b></u>\n \u1793\u17B7\u1784\u1798\u17B6\u1793\u1790\u17D2\u1784\u17C3\u1781\u17C2\u1786\u17D2\u1793\u17B6\u17C6\u1780\u17C6\u178E\u17BE\u178F\n <u><b>\n <%= rep_certification_info.date_of_birth %>\n </b></u>\n \u1796\u17B7\u178F\u1787\u17B6\u179A\u1794\u179F\u17CB\u17A2\u17D2\u1793\u1780\u178A\u17B6\u1780\u17CB\u1796\u17B6\u1780\u17D2\u1799\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u1796\u17B7\u178F\u1794\u17D2\u179A\u17B6\u1780\u178A\u1798\u17C2\u1793\u17D4\n </p>\n <br>\n <p class=\"text-justify\">\n I have personally seen the Applicant and the Life Assured and have explained the terms and\n conditions of the policy to\n the Applicant.\n I have seen the ID of the Applicant and original copy. I certify that the date of birth and ID\n number truly belong to\n the Applicant.\n </p>\n <br><br><br><br>\n \n <!-- Signature -->\n <p>\n <span>\u17A0\u178F\u17D2\u1790\u179B\u17C1\u1781\u17B6 \u1793\u17B7\u1784\u1788\u17D2\u1798\u17C4\u17C7</span>\n <span> / Signature and name: </span>\n <u>\n <span style=\"text-transform: uppercase; font-weight: bold\">\n <%= rep_certification_info.rep_full_name %>\n </span>\n </u>\n </p>\n </td>\n </tr>\n </tbody>\n </table>\n </div>\n \n <div class=\"question-row declaration-header\">\n <table style=\"margin-top: 10px; width: 100%; table-layout: fixed;\" class=\"form-table\" cellpadding=\"15\">\n <tbody>\n <!-- Header -->\n <tr>\n <td colspan=\"3\" style=\"text-align: center;\" class=\"text-lg font-bold\">\n <h5>\u17A0\u17D2\u179C\u17B8\u179B\u17B8\u1796 \u17A1\u17B6\u1799\u17A0\u17D2\u179C\u17CD \u17A2\u17B6\u179F\u17BD\u179A\u17C1\u1793 (\u1781\u17C1\u1798\u1794\u17BC\u178C\u17B6) \u1798.\u1780</h5>\n <h5>Phillip Life Assurance (Cambodia) Plc</h5>\n </td>\n </tr>\n <!-- Content -->\n <tr>\n <td style=\"text-align: left;\" colspan=\"3\">\n <div>\n <span>\u179F\u1798\u17D2\u179A\u17B6\u1794\u17CB\u1794\u17D2\u179A\u17BE\u1780\u17D2\u1793\u17BB\u1784\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793\u178F\u17C2\u1794\u17C9\u17BB\u178E\u17D2\u178E\u17C4\u17C7</span>\n <span>/ For office Use Only:</span>\n \n <p style=\"text-align: left;\">\n <span>\u179B\u17C1\u1781\u1796\u17B6\u1780\u17D2\u1799\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784</span>\n <span>/ Application Number:</span>\n <span style=\"font-weight: bold\">\n <%= agent_source_info.application_no %>\n </span>\n </p>\n <p style=\"text-align: left;\">\n <span>\u179B\u17C1\u1781\u179F\u1798\u17D2\u1782\u17B6\u179B\u17CB\u17A2\u178F\u17B7\u1790\u17B7\u1787\u1793</span>\n <span>/ Client Number:</span>\n <span style=\"font-weight: bold\">\n <%= agent_source_info.client_no %>\n </span>\n </p>\n <p style=\"text-align: left;\">\n <span>\u179B\u17C1\u1781\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784</span>\n <span>/ Policy Number:</span>\n <span style=\"font-weight: bold\">\n <%= agent_source_info.policy_no %>\n </span>\n </p>\n <p style=\"text-align: left;\">\n <span>\u179B\u17C1\u1781\u179F\u1798\u17D2\u1782\u17B6\u179B\u17CB\u1794\u17D2\u179A\u1797\u1796</span>\n <span>/ Source Code:</span>\n <span style=\"font-weight: bold\">\n <%= agent_source_info.source_code %>\n </span>\n </p>\n <p style=\"text-align: left;\">\n <span>\u179B\u17C1\u1781\u179F\u1798\u17D2\u1782\u17B6\u179B\u17CB\u17A2\u17D2\u1793\u1780\u1794\u17D2\u179A\u17B9\u1780\u17D2\u179F\u17B6\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784</span>\n <span>/ Insurance Advisor Code:</span>\n <span style=\"font-weight: bold\">\n <%= agent_source_info.advisor_code %>\n </span>\n </p>\n <p style=\"text-align: left;\">\n <span>\u179B\u17C1\u1781\u1791\u17BC\u179A\u179F\u17D0\u1796\u17D2\u1791\u17A2\u17D2\u1793\u1780\u1794\u17D2\u179A\u17B9\u1780\u17D2\u179F\u17B6\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784</span>\n <span>/ Insurance Advisor Contact Number:</span>\n <span style=\"font-weight: bold\">\n <%= agent_source_info.advisor_contact %>\n </span>\n </p>\n </div>\n </td>\n </tr>\n \n </tbody>\n </table>\n <div class=\"mt-5 space-y-2\">\n <p>\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u179B\u1798\u17D2\u17A2\u17B7\u178F\u1794\u1793\u17D2\u1790\u17C2\u1798:\n \u179F\u17BC\u1798\u1794\u17D2\u179A\u17BE\u1794\u17D2\u179A\u17B6\u179F\u17CB\u1780\u1793\u17D2\u179B\u17C2\u1784\u1781\u17B6\u1784\u1780\u17D2\u179A\u17C4\u1798\u178A\u17BE\u1798\u17D2\u1794\u17B8\u1786\u17D2\u179B\u17BE\u1799\u1793\u17B9\u1784\u179F\u17C6\u178E\u17BD\u179A\u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17BE\u1791\u17C6\u17A0\u17C6\u1793\u17C5\u1780\u17D2\u1793\u17BB\u1784\u1780\u1798\u17D2\u179A\u1784\u179F\u17C6\u178E\u17BD\u179A\u1781\u17B6\u1784\u179B\u17BE\u1798\u17B7\u1793\u1782\u17D2\u179A\u1794\u17CB\u1782\u17D2\u179A\u17B6\u1793\u17CB\u17D4</p>\n <p>Additional Details: Please use the space bellow if there are insufficient space in the\n questionnaire to provide your answers.</p>\n </div>\n </div>\n \n \n </div>\n </div>\n </div>\n </body>\n\n</html>\n";
1
+ export declare const UW_FORM_TEMPLATE = "\n<!doctype html>\n<html lang=\"en\">\n\n<head>\n <meta charset=\"UTF-8\" />\n <meta name=\"viewport\" content=\"width=device-width, initial-scale=1.0\" />\n <title>FULL UW APPLICATION FORM</title>\n\n <link href=\"https://fonts.googleapis.com/css2?family=Hanuman:wght@100..900&family=Moul&display=swap\"\n rel=\"stylesheet\" />\n <script src=\"https://cdn.tailwindcss.com\"></script>\n\n <style>\n * {\n margin: 0;\n box-sizing: border-box;\n background: none;\n }\n\n body {\n font-family: \"Hanuman\", sans-serif;\n margin: 0;\n font-size: 16px;\n }\n\n .font-moul {\n font-family: \"Moul\", sans-serif;\n }\n\n .font-arial {\n font-family: Arial, sans-serif;\n }\n\n .form-table td {\n border: 1px solid black;\n }\n\n .no-border td {\n border-top: none !important;\n border-bottom: none !important;\n }\n\n .form-field-line {\n border-bottom: 1px solid #000;\n min-height: 18px;\n width: 100%;\n display: block;\n margin-top: 4px;\n }\n\n input[type=\"checkbox\"] {\n width: 18px;\n height: 18px;\n margin-right: 5px;\n vertical-align: middle;\n accent-color: #000;\n }\n\n @media print {\n @page {\n size: A3 portrait;\n margin: 10mm 10mm 20mm 10mm;\n }\n }\n\n .page {\n width: 297mm;\n /* A3 portrait width */\n min-height: 420mm;\n /* A3 portrait height */\n padding: 10mm;\n box-sizing: border-box;\n position: relative;\n page-break-after: always;\n break-after: page;\n overflow: hidden;\n }\n\n .question-row {\n page-break-inside: avoid;\n break-inside: avoid;\n }\n </style>\n\n</head>\n\n<% function yesNoCheckbox(value, name) { return '<div class=\"flex items-center gap-2\" style=\"margin-top:3px;\">' + '<input type=\"checkbox\" ' + (value===true ? 'checked' : '') + ' />' + '<span>\u1798\u17B6\u1793 / Yes</span>' + '&nbsp;&nbsp;' + '<input type=\"checkbox\" ' + (value===false ? 'checked' : '') + ' />' + '<span>\u1798\u17B7\u1793\u1798\u17B6\u1793 / No</span>' + '</div>';\n }\n %>\n\n\n <% function renderField(value) { const hasValue=value && value.toString().trim(); return '<div style=\"border-bottom:1px solid #000;min-height:18px;width:100%;display:block;margin-top:4px;\">' + (hasValue ? '<span style=\"font-weight:bold;\">' + value + '</span>' : '&nbsp;') + '</div>';\n } %>\n\n <% function renderCheck(value, expected) { return value===expected\n ? '<span style=\"font-size:16px; font-weight:bold;\">&#10003;</span>' : '' ; } %>\n\n <body>\n <script>\n document.fonts.ready.then(() => {\n paginateRows();\n });\n\n function paginateRows() {\n const PAGE_HEIGHT_PX = 1511;\n const wrapper = document.getElementById('pages-wrapper');\n const allRows = Array.from(document.querySelectorAll('.question-row'));\n\n let currentPage = document.getElementById('main-content');\n let currentTable = currentPage.querySelector('table');\n let currentDiv = currentPage;\n let usedHeight = currentPage.getBoundingClientRect().height;\n let pageNum = 1;\n\n function createNewPage() {\n pageNum++;\n const newPage = document.createElement('div');\n newPage.className = 'page';\n\n const newTable = document.createElement('table');\n newTable.className = 'table w-full table-fixed border-collapse form-table';\n newTable.setAttribute('cellpadding', '20');\n newPage.appendChild(newTable);\n wrapper.appendChild(newPage);\n\n currentTable = newTable;\n currentDiv = newPage;\n usedHeight = 0;\n }\n\n for (const row of allRows) {\n const isDeclaration = row.classList.contains('declaration-header');\n const isTr = row.tagName === 'TR';\n const container = isTr ? currentTable : currentDiv;\n\n // Measure\n row.style.visibility = 'hidden';\n container.appendChild(row);\n const rowH = row.getBoundingClientRect().height;\n container.removeChild(row);\n row.style.visibility = '';\n\n const remaining = PAGE_HEIGHT_PX - usedHeight;\n\n if (usedHeight + rowH > PAGE_HEIGHT_PX || (isDeclaration && remaining < 300)) {\n createNewPage();\n }\n\n const target = row.tagName === 'TR' ? currentTable : currentDiv;\n target.appendChild(row);\n usedHeight += rowH;\n }\n }\n </script>\n \n <div id=\"pages-wrapper\">\n <div class=\"page\">\n <div id=\"first-off-page\">\n <div class=\"space-y-3\">\n <table width=\"100%\" cellpadding=\"20\">\n <colgroup>\n <col style=\"width: 20%\" />\n <col style=\"width: 80%\" />\n </colgroup>\n <tr style=\"text-align:center;\">\n <th style=\"background:#ebebeb; border:1px solid;\">\n <img src=\"data:image/png;base64,<%= logo_base64 %>\" alt=\"Logo\" class=\"title-logo\" width=\"200px\" />\n </th>\n \n <th style=\"background:#dddddd; border:1px solid;\" class=\"space-y-2\">\n <p class=\"font-moul text-2xl\">\n \u1796\u17B6\u1780\u17D2\u1799\u179F\u17C1\u17B8\u17D2\u1793\u179F\u17BB\u17C6\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u17A2\u17B6\u1799\u17BB\u1787\u17B8\u179C\u17B7\u178F\n </p>\n <p class=\"text-lg\">\n LIFE ASSURANCE APPLICATION FORM\n </p>\n </th>\n </tr>\n </table>\n \n <div class=\"space-y-2 text-align\">\n <p>\u179F\u17BC\u1798\u1795\u17D2\u178F\u179B\u17CB\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u1798\u1780\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793\u17B1\u17D2\u1799\u1794\u17B6\u1793\u1782\u17D2\u179A\u1794\u17CB\u1782\u17D2\u179A\u17B6\u1793\u17CB \u1793\u17B7\u1784\u178F\u17D2\u179A\u17B9\u1798\u178F\u17D2\u179A\u17BC\u179C\u17D4 \u1780\u17B6\u179A\u1795\u17D2\u178F\u179B\u17CB\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u1798\u17B7\u1793\u178F\u17D2\u179A\u17B9\u1798\u178F\u17D2\u179A\u17BC\u179C \u17AC\u1780\u17D2\u179B\u17C2\u1784\u1794\u1793\u17D2\u179B\u17C6\n \u1793\u17B6\u17C6\u17B1\u17D2\u1799\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u1798\u17C4\u1783\u1797\u17B6\u1796 \u17AC\u178F\u17D2\u179A\u17BC\u179C\u179B\u17BB\u1794\u1785\u17C4\u179B\u17D4</p>\n <p>Please provide us with complete and accurate information. Providing wrong or false information may\n result\n in\n the policy issued being cancelled or voided.</p>\n </div>\n \n <table class=\"table w-full table-fixed border-collapse form-table\" cellpadding=\"10\">\n <colgroup>\n <col style=\"width: 17%\">\n <col style=\"width: 17%\">\n <col style=\"width: 8%\">\n <col style=\"width: 8%\">\n <col style=\"width: 17%\">\n <col style=\"width: 17%\">\n <col style=\"width: 8%\">\n <col style=\"width: 8%\">\n </colgroup>\n <thead>\n <tr>\n <th colspan=\"4\" class=\"w-1/2 border border-black\">\n <p>\u1795\u17D2\u1793\u17C2\u1780\u1791\u17B8\u17E1: \u200B\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u17A2\u17C6\u1796\u17B8\u1798\u17D2\u1785\u17B6\u179F\u17CB\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784</p>\n <p>Part 1: INFORMATION ABOUT THE POLICYHOLDER</p>\n </th>\n \n <th colspan=\"4\" class=\"w-1/2 border border-black\">\n <p>\u1795\u17D2\u1793\u17C2\u1780\u1791\u17B8\u17E1: \u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u17A2\u17C6\u1796\u17B8\u17A2\u17D2\u1793\u1780\u178F\u17D2\u179A\u17BC\u179C\u1794\u17B6\u1793\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784</p>\n <p>( \u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17C1\u17B8\u1781\u17BB\u179F\u1796\u17B8\u1798\u17D2\u1785\u17B6\u179F\u17CB\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784 )</p>\n <p>Part 1: INFORMATION ABOUT THE LIFE ASSURED</p>\n <p>( if different from the policyholder )</p>\n </th>\n </tr>\n \n <!-- Full Name Value -->\n <tr>\n <td colspan=\"4\">\n <p>\u1788\u17D2\u1798\u17C1\u17B6\u17C7\u1796\u17C1\u1789\u178A\u17BC\u1785\u1794\u1784\u17D2\u17A0\u17B6\u1789\u1793\u17C5\u1780\u17D2\u1793\u17BB\u1784\u17A2\u178F\u17D2\u178F\u179F\u1789\u17D2\u1789\u17B6\u178E\u1794\u178E\u17D2\u178E / \u179B\u17B7\u1781\u17B7\u178F\u1786\u17D2\u179B\u1784\u178A\u17C2\u1793 / \u179F\u17C6\u1794\u17BB\u178F\u17D2\u179A\u1780\u17C6\u178E\u17C1\u17B8\u178F / \u1794\u17D0\u178E\u17D2\u178E\u1794\u17C9\u17B6\u178F\u1784\u17CB\n (\u1787\u17B6\u1797\u17B6\u179F\u17B6\u1781\u17D2\u1798\u17C2\u179A \u1793\u17B7\u1784\u17A2\u1784\u17CB\u1782\u17D2\u179B\u17C1\u179F)</p>\n <p class=\" \">Full name as shown in ID card / Passport / Birth Certificate / Patent Tax (Khmer\n and\n English)</p>\n </td>\n <td colspan=\"4\">\n <p>\u1788\u17D2\u1798\u17C1\u17B6\u17C7\u1796\u17C1\u1789\u178A\u17BC\u1785\u1794\u1784\u17D2\u17A0\u17B6\u1789\u1793\u17C5\u1780\u17D2\u1793\u17BB\u1784\u17A2\u178F\u17D2\u178F\u179F\u1789\u17D2\u1789\u17B6\u178E\u1794\u178E\u17D2\u178E / \u179B\u17B7\u1781\u17B7\u178F\u1786\u17D2\u179B\u1784\u178A\u17C2\u1793 / \u179F\u17C6\u1794\u17BB\u178F\u17D2\u179A\u1780\u17C6\u178E\u17C1\u17B8\u178F (\u1787\u17B6\u1797\u17B6\u179F\u17B6\u1781\u17D2\u1798\u17C2\u179A\n \u1793\u17B7\u1784\u17A2\u1784\u17CB\u1782\u17D2\u179B\u17C1\u179F)</p>\n <p class=\" \">Full name as shown in ID card / Passport / Birth Certificate (Khmer and English)\n </p>\n </td>\n </tr>\n <tr>\n <td colspan=\"4\">\n <span class=\"font-bold text-md\">\n <%= ph.full_name %>\n </span>\n </td>\n <td colspan=\"4\">\n <span class=\"font-bold text-md\">\n <%= la.full_name %>\n </span>\n </td>\n </tr>\n \n <!-- Present Address Label -->\n <tr>\n <td colspan=\"4\">\n <span class=\"\">\u17A2\u17B6\u179F\u1799\u178A\u17D2\u178B\u17B6\u1793\u1794\u1785\u17D2\u1785\u17BB\u1794\u17D2\u1794\u1793\u17D2\u1793 /</span>\n <span class=\" \">Present Address</span>\n </td>\n <td colspan=\"4\">\n <span class=\"\">\u17A2\u17B6\u179F\u1799\u178A\u17D2\u178B\u17B6\u1793\u1794\u1785\u17D2\u1785\u17BB\u1794\u17D2\u1794\u1793\u17D2\u1793 /</span>\n <span class=\" \">Present Address</span>\n </td>\n </tr>\n <tr>\n <td colspan=\"4\">\n <span class=\"font-bold\">\n <%= ph.present_address %>\n </span>\n </td>\n <td colspan=\"4\">\n <span class=\"font-bold\">\n <%= la.present_address %>\n </span>\n </td>\n </tr>\n \n <!-- Phone / Relationship Label -->\n <tr>\n <td colspan=\"4\">\n <ol class=\"list-decimal pl-5\">\n <li>\n <span>\u179B\u17C1\u1781\u1791\u17BC\u179A\u179F\u17D0\u1796\u17D2\u1791\u1795\u17D2\u1791\u17B6\u179B\u17CB\u1781\u17D2\u179B\u17BD\u1793 / \u17A2\u17BB\u17B8\u1798\u17C9\u17C2\u179B /</span>\n <span>Phone Number / Email</span>\n </li>\n <li>\n <span>\u1791\u17C6\u1793\u17B6\u1780\u17CB\u1791\u17C6\u1793\u1784\u1787\u17B6\u1798\u17BD\u1799\u17A2\u17D2\u1793\u1780\u178F\u17D2\u179A\u17BC\u179C\u1794\u17B6\u1793\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784 /</span>\n <span>Relationship to Life Assured</span>\n </li>\n </ol>\n </td>\n \n <td colspan=\"4\">\n <ol class=\"list-decimal pl-5\">\n <li>\n <span>\u179B\u17C1\u1781\u1791\u17BC\u179A\u179F\u17D0\u1796\u17D2\u1791\u1795\u17D2\u1791\u17B6\u179B\u17CB\u1781\u17D2\u179B\u17BD\u1793 / \u17A2\u17BB\u17B8\u1798\u17C9\u17C2\u179B /</span>\n <span>Phone Number / Email</span>\n </li>\n <li>\n <span>\u1791\u17C6\u1793\u17B6\u1780\u17CB\u1791\u17C6\u1793\u1784\u1787\u17B6\u1798\u17BD\u1799\u1798\u17D2\u1785\u17B6\u179F\u17CB\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784 /</span>\n <span>Relationship to Policyholder</span>\n </li>\n </ol>\n </td>\n </tr>\n \n <tr class=\"font-bold\">\n <td colspan=\"4\">\n <ol class=\"list-decimal pl-5\">\n <li>\n <span>Primary Contact: <%= ph.contact_info %> </span>\n </li>\n <li>\n <span>\n <%= ph.ph_la_relationship %>\n </span>\n </li>\n </ol>\n </td>\n \n <td colspan=\"4\">\n <ol class=\"list-decimal pl-5\">\n <li>\n <span>Primary Contact: <%= la.contact_info %> </span>\n </li>\n <li>\n <span>\n <%= la.ph_la_relationship %>\n </span>\n </li>\n </ol>\n </td>\n </tr>\n \n <!-- PH = LA / PH \u2260 LA -->\n <tr>\n <td colspan=\"4\">\n <div class=\"flex items-center gap-2\">\n <input type=\"checkbox\" <%=isphla_same_person ? 'checked' : '' %> />\n <span>\u1798\u17D2\u1785\u17B6\u179F\u17CB\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784 = \u17A2\u17D2\u1793\u1780\u178F\u17D2\u179A\u17BC\u179C\u1794\u17B6\u1793\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784</span>\n <span>/</span>\n <span>PH = LA</span>\n </div>\n </td>\n <td colspan=\"4\">\n <div class=\"flex items-center gap-2\">\n <input type=\"checkbox\" <%=!isphla_same_person ? 'checked' : '' %> />\n <span>\u1798\u17D2\u1785\u17B6\u179F\u17CB\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784 </span> &ne; <span>\u17A2\u17D2\u1793\u1780\u178F\u17D2\u179A\u17BC\u179C\u1794\u17B6\u1793\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784</span>\n <span>/</span>\n <span>PH \u2260 LA</span>\n </div>\n </td>\n </tr>\n \n <!-- Nationality / ID / Gender / Age Labels -->\n <% const headers=[ { kh: \"\u179F\u1789\u17D2\u1787\u17B6\u178F\u17B7\" , en: \"Nationality\" }, { kh: \"\u179B\u17C1\u1781\u17A2\u178F\u17D2\u178F\u179F\u1789\u17D2\u1789\u17B6\u178E\u1794\u17D0\u178E\u17D2\u178E/\u179B\u17B7\u1781\u17B7\u178F\u1786\u17D2\u179B\u1784\u178A\u17C2\u1793\" ,\n en: \"ID / Passport Number\" }, { kh: \"\u1797\u17C1\u1791\" , en: \"Gender\" }, { kh: \"\u17A2\u17B6\u1799\u17BB\" , en: \"Age\" } ]; %>\n \n <tr>\n <% for (let i=0; i < 2; i++) { %>\n <% headers.forEach((h, idx)=> { %>\n \n <td class=\"align-top <%= idx === headers.length - 1 ? 'text-center' : 'text-start' %>\">\n <div class=\"flex flex-col justify-center h-full\">\n <p class=\"text-sm\">\n <%= h.kh %>\n </p>\n <p class=\"text-sm\">\n <%= h.en %>\n </p>\n </div>\n </td>\n \n <% }) %>\n <% } %>\n </tr>\n \n <!-- Nationality / ID / Gender / Age Values -->\n <tr>\n <td class=\"text-start-top\">\n <p class=\"font-bold\">\n <%= ph.nationality %>\n </p>\n </td>\n <td class=\"text-start-top\">\n <p class=\"font-bold\">\n <%= ph.identifier_no %>\n </p>\n </td>\n <td class=\"text-start-top\">\n <p class=\"font-bold\">\n <%= ph.gender %>\n </p>\n </td>\n <td class=\"text-start-top text-center\">\n <span class=\"font-bold\">\n <%= ph.age %>\n </span>\n </td>\n \n <td class=\"text-start-top\">\n <p class=\"font-bold\">\n <%= la.nationality %>\n </p>\n </td>\n <td class=\"text-start-top\">\n <p class=\" font-bold\">\n <%= la.identifier_no %>\n </p>\n </td>\n <td class=\"text-start-top\">\n <p class=\"font-bold\">\n <%= la.gender %>\n </p>\n </td>\n <td class=\"text-start-top text-center\">\n <span class=\"font-bold \">\n <%= la.age %>\n </span>\n </td>\n </tr>\n \n <!-- DOB / Marital / Children Labels -->\n <% const fields=[ { kh: \"\u1790\u17D2\u1784\u17C3\u1781\u17C2\u1786\u17D2\u1793\u17B6\u17C6 \u1793\u17B7\u1784\u1791\u17B8\u1780\u1793\u17D2\u179B\u17C2\u1784\u1780\u17C6\u178E\u17BE\u178F\" , en: \"Date and Place of Birth\" , colspan: 1 }, {\n kh: \"\u1793\u17C5\u179B\u17B8\u179C / \u179A\u17C0\u1794\u1780\u17B6\u179A\u179A\u17BD\u1785 / \u179B\u17C2\u1784\u179B\u17C7 / \u1796\u17C4\u17C7\u1798\u17C9\u17B6\u1799 \u17AC\u1798\u17C1\u1798\u17C9\u17B6\u1799\" , en: \"Single / Married / Divorced / Widowed\" , colspan: 1 }, {\n kh: \"\u1785\u17C6\u1793\u17BD\u1793\u1780\u17BC\u1793\" , en: \"Number of Children\" , colspan: 2 } ]; %>\n \n <tr>\n <% for (let i=0; i < 2; i++) { %>\n <% fields.forEach(field=> { %>\n\n <td colspan=\"<%= field.colspan %>\" class=\"text-start-top align-top\">\n <p class=\"text-sm\">\n <%= field.kh %>\n </p>\n <p class=\"text-sm\">\n <%= field.en %>\n </p>\n </td>\n \n <% }) %>\n <% } %>\n </tr>\n \n <tr>\n <td class=\"text-start-top\" style=\"line-height:1.7\">\n <p class=\"font-bold text-sm\">\n <%= ph.dob_and_pob || '' %>\n </p>\n </td>\n <td class=\"text-start-top text-center\">\n <p class=\"font-bold\">\n <%= ph.martial_status %>\n </p>\n </td>\n <td colspan=\"2\" class=\"text-start-top text-center\">\n <p class=\" font-bold\">\n <%= ph.number_of_children %>\n </p>\n </td>\n \n <td class=\"text-start-top\" style=\"line-height:1.7\">\n <p class=\"font-bold text-sm\">\n <%= la.dob_and_pob || '' %>\n </p>\n </td>\n <td class=\"text-start-top text-center\">\n <p class=\" font-bold\">\n <%= la.martial_status %>\n </p>\n </td>\n <td colspan=\"2\" class=\"text-start-top text-center\">\n <p class=\" font-bold\">\n <%= la.number_of_children %>\n </p>\n </td>\n </tr>\n \n <!-- Employer Name Label -->\n <tr>\n <td colspan=\"4\">\n <span>\u1788\u17D2\u1798\u17C4\u17C7 \u1793\u17B7\u1784\u17A2\u17B6\u179F\u1799\u178A\u17D2\u178B\u17B6\u1793\u179A\u1794\u179F\u17CB\u1793\u17B7\u1799\u17C4\u1787\u1780 /</span>\n <span>Name and Address of Employer</span>\n </td>\n <td colspan=\"4\">\n <span>\u1788\u17D2\u1798\u17C4\u17C7 \u1793\u17B7\u1784\u17A2\u17B6\u179F\u1799\u178A\u17D2\u178B\u17B6\u1793\u179A\u1794\u179F\u17CB\u1793\u17B7\u1799\u17C4\u1787\u1780 /</span>\n <span>Name and Address of Employer</span>\n </td>\n </tr>\n \n <!-- Employer Name Value -->\n <tr>\n <td colspan=\"4\">\n <span class=\"font-khmer font-bold\">\n <%= ph.name_and_address_of_employer || 'N/A' %>\n </span>\n </td>\n <td colspan=\"4\">\n <span class=\"font-khmer font-bold\">\n <%= la.name_and_address_of_employer || 'N/A' %>\n </span>\n </td>\n </tr>\n \n <!-- Job Title / Salary Labels -->\n <% const jobFields=[ { kh: \"\u178F\u17BD\u1793\u17B6\u1791\u17B8 \u1793\u17B7\u1784\u1794\u17D2\u179A\u1797\u17C1\u1791\u1793\u17C3\u1780\u17B6\u179A\u1784\u17B6\u179A\" , en: \"Job Title and Nature of Work\" , colspan: 2 }, {\n kh: \"\u1794\u17D2\u179A\u17B6\u1780\u17CB\u1794\u17C0\u179C\u178F\u17D2\u179F\u1794\u17D2\u179A\u1785\u17C6\u17B6\u1786\u17D2\u1793\u17B6\u17C6\" , en: \"Annual Salary\" , colspan: 2 } ]; %>\n <tr>\n <% for (let i=0; i < 2; i++) { %>\n <% jobFields.forEach(field=> { %>\n <td colspan=\"<%= field.colspan %>\">\n <p>\n <%= field.kh %>\n </p>\n <p>\n <%= field.en %>\n </p>\n </td>\n <% }) %>\n <% } %>\n </tr>\n \n <!-- Job Title / Salary Values -->\n <tr>\n <td colspan=\"2\"><span class=\"font-khmer font-bold\">\n <%= ph.job_title %>\n </span></td>\n <td colspan=\"2\"><span class=\"font-khmer font-bold\">\n <%= ph.annual_salary %>\n </span></td>\n \n <td colspan=\"2\"><span class=\"font-khmer font-bold\">\n <%= la.job_title %>\n </span></td>\n <td colspan=\"2\"><span class=\"font-khmer font-bold\">\n <%= la.annual_salary %>\n </span></td>\n </tr>\n <!-- USA Green Card -->\n <tr>\n <td colspan=\"8\">\n <span>\u1798\u17D2\u1785\u17B6\u179F\u17CB\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u1798\u17B7\u1793\u1798\u17C2\u1793\u1787\u17B6\u1796\u179B\u179A\u178A\u17D2\u178B\u17A2\u17B6\u1798\u17C1\u179A\u17B7\u1780 \u17AC \u1787\u17B6\u1794\u17CB\u1796\u1793\u17D2\u1792\u179F\u17D2\u1793\u17B6\u1780\u17CB\u1793\u17C5\u17A2\u17B6\u1798\u17C1\u179A\u17B7\u1780 \u17AC\n \u1798\u17B6\u1793\u179F\u17B7\u1791\u17D2\u1792\u17B7\u1780\u17B6\u1793\u17CB</span>\n <span> Green Card </span>\n <span>\u1793\u17C4\u17C7\u1791\u17C1\u17D4 </span>\n <p>\n <span>The Policyholder is not USA citizen / USA resident for tax purpose or holding\n Green\n Card.</span>\n </p>\n <%- yesNoCheckbox(ph_is_not_us_citizen) %>\n </td>\n </tr>\n </thead>\n </table>\n </div>\n \n <!-- page break -->\n <div style=\"page-break-after: always;\"></div>\n <!-- table 2 question -->\n <table class=\"table w-full table-fixed border-collapse form-table\" cellpadding=\"10\">\n <colgroup>\n <col style=\"width: 40%\">\n <col style=\"width: 30%\">\n <col style=\"width: 30%\">\n </colgroup>\n <!-- Only Life Assured Notice -->\n <tr>\n <td colspan=\"3\" class=\"text-lg font-bold\" style=\"text-align:center;\">\n <h5>\n \u17A2\u17D2\u1793\u1780\u178F\u17D2\u179A\u17BC\u179C\u1794\u17B6\u1793\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u178F\u17C2\u1794\u17C9\u17BB\u178E\u17D2\u178E\u17C4\u17C7\u178A\u17C2\u179B\u178F\u1798\u17D2\u179A\u17BC\u179C\u17B1\u17D2\u1799\u1794\u17C6\u1796\u17C1\u1789\u1795\u17D2\u1793\u17C2\u1780\u178A\u17C2\u179B\u1793\u17C5\u179F\u179B\u17CB\u1793\u17C3\u1791\u1798\u17D2\u179A\u1784\u17CB\u1796\u17B6\u1780\u17D2\u1799\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u1793\u17C1\u17C7</h5>\n <h5>ONLY THE LIFE ASSURED'S INFORMATION IS REQUIRED FOR THE REMAINDER OF THIS\n APPLICATION FORM</h5>\n </td>\n </tr>\n \n <tr>\n <td colspan=\"3\">\n <span>\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u17A2\u17C6\u1796\u17B8\u179A\u1794\u17C0\u1794\u179A\u179F\u17CB\u1793\u17C5 \u1793\u17B7\u1784\u17A0\u17B6\u1793\u17B7\u1797\u17D0\u1799</span> / <span>Lifestyle and Risk Information</span>\n </td>\n </tr>\n \n <!-- Dangerous Activities -->\n \n <!-- Military Flying -->\n <tr class=\"no-border\">\n <td colspan=\"3\">\n <p>\u178F\u17BE\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u1780\u17C6\u1796\u17BB\u1784 \u17AC\u1798\u17B6\u1793\u1782\u1798\u17D2\u179A\u17C4\u1784\u1792\u17D2\u179C\u17BE\u1780\u17B6\u179A\u17A0\u17C4\u17C7\u17A0\u17BE\u179A\u1787\u17B6\u179B\u1780\u17D2\u1781\u178E\u17C8\u1799\u17C4\u1792\u17B6 \u17AC\u17AF\u1780\u1787\u1793\n \u1780\u17D2\u179A\u17C5\u1796\u17B8\u17A2\u17D2\u1793\u1780\u178A\u17C6\u178E\u17BE\u179A\u178F\u17B6\u1798\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793\u17A2\u17B6\u1780\u17B6\u179F\u1785\u179A\u178E\u17CD\u1792\u1798\u17D2\u1798\u178F\u17B6\u178A\u17C2\u179A\u17AC\u1791\u17C1?</p>\n \n <p>Do you take part in or do you plan to take part in military or private flying other\n than as a passenger on a regular airline?</p>\n \n <%- yesNoCheckbox(la_lifestyle.military_or_flying) %>\n </td>\n </tr>\n \n <!-- Dangerous Occupations Header -->\n <tr class=\"no-border\">\n <td colspan=\"3\">\n <p>\u178F\u17BE\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u1780\u17C6\u1796\u17BB\u1784 \u17AC\u1798\u17B6\u1793\u1782\u1798\u17D2\u179A\u17C4\u1784\u1793\u17B9\u1784\u1798\u17B6\u1793\u17A2\u17B6\u1787\u17B8\u1796\n \u17AC\u1792\u17D2\u179C\u17BE\u179F\u1780\u1798\u17D2\u1798\u1797\u17B6\u1796\u1782\u17D2\u179A\u17C4\u17C7\u1790\u17D2\u1793\u17B6\u1780\u17CB\u178A\u17BC\u1785\u1798\u17B6\u1793\u179A\u17C0\u1794\u179A\u17B6\u1794\u17CB\u1793\u17C5\u1781\u17B6\u1784\u1780\u17D2\u179A\u17C4\u1798\u1793\u17C1\u17C7\u178A\u17C2\u179A\u17AC\u1791\u17C1?</p>\n <p>Do you take part in, or plan to take part in any of these listed dangerous occupations or\n pursuits?</p>\n </td>\n </tr>\n \n <!-- Scuba / Rock Climbing -->\n <tr class=\"no-border\">\n <td colspan=\"3\">\n <span>\u1787\u17D2\u179A\u1798\u17BB\u1787\u1791\u17B9\u1780\u1782\u17D2\u179A\u1794\u17CB\u1794\u17D2\u179A\u1797\u17C1\u1791 \u17A1\u17BE\u1784\u1790\u17D2\u1798 \u17AC\u17A1\u17BE\u1784\u1797\u17D2\u1793\u17C6 / Scuba Skin diving Mountain or rock climbing</span>\n <%- yesNoCheckbox(la_lifestyle.diving_or_climbing) %>\n </td>\n </tr>\n \n <!-- Parachuting / Motor Racing -->\n <tr class=\"no-border\">\n <td colspan=\"3\">\n <span>\u179B\u17C4\u178F\u1786\u17D0\u178F\u17D2\u179A\u1799\u17C4\u1784 \u1794\u17D2\u179A\u178E\u17B6\u17C6\u1784\u1798\u17C9\u17BC\u178F\u17BC / Free fall parachuting Motor racing</span>\n <%- yesNoCheckbox(la_lifestyle.parachuting_or_racing) %>\n </td>\n </tr>\n \n <!-- Other -->\n <tr class=\"no-border\">\n <td colspan=\"3\">\n <span>\u1795\u17D2\u179F\u17C1\u1784\u17D7\u1791\u17C0\u178F \u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17BE\u1798\u17B6\u1793\u179F\u17BC\u1798\u1794\u1789\u17D2\u1787\u17B6\u1780\u17CB / Other if yes please provide more details : <%-\n renderField(la_lifestyle.activity_detail_desc) %></span>\n </td>\n </tr>\n \n <!-- Travel Abroad -->\n <tr class=\"no-border border-t border-black\">\n <td colspan=\"3\">\n <p>\u178F\u17BE\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u179F\u17D2\u1793\u17B6\u1780\u17CB\u1793\u17C5 \u17AC \u1798\u17B6\u1793\u1782\u1798\u17D2\u179A\u17C4\u1784\u179F\u17D2\u1793\u17B6\u1780\u17CB\u1793\u17C5\u1780\u17D2\u179A\u17C5\u1794\u17D2\u179A\u1791\u17C1\u179F\u179B\u17BE\u179F\u1796\u17B8\u179A\u1799\u17C8\u1796\u17C1\u179B\u17E3\u1781\u17C2 \u1780\u17D2\u1793\u17BB\u1784\u17E1\u1786\u17D2\u1793\u17B6\u17C6\u178A\u17C2\u179A\u17AC\u1791\u17C1?</p>\n <p>Do you plan to reside or travel abroad for more than three months a year?</p>\n <%- yesNoCheckbox(la_lifestyle.reside_or_travel_abroad) %>\n </td>\n </tr>\n <tr class=\"no-border\">\n <td colspan=\"3\">\n <p>\u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17BE\u1798\u17B6\u1793\u179F\u17BC\u1798\u1795\u17D2\u178F\u179B\u17CB\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u179B\u1798\u17D2\u17A2\u17B7\u178F\u17A2\u17C6\u1796\u17B8\u17A2\u17B6\u179F\u1799\u178A\u17D2\u178B\u17B6\u1793\u179A\u1794\u179F\u17CB\u1794\u17D2\u179A\u1791\u17C1\u179F\u178A\u17C2\u179B\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u179F\u17D2\u1793\u17B6\u1780\u17CB\u1793\u17C5 \u17AC\n \u1798\u17B6\u1793\u1782\u1798\u17D2\u179A\u17C4\u1784\u179F\u17D2\u1793\u17B6\u1780\u17CB\u1793\u17C5 \u17AC\u1792\u17D2\u179C\u17BE\u178A\u17C6\u178E\u17BE\u179A\u178A\u17BC\u1785\u1781\u17B6\u1784\u1780\u17D2\u179A\u17C4\u1798:</p>\n <p class=\"mb-3\">\n If yes, please provide detail information about address of country that reside / travel as\n following :\n </p>\n <span> <%- renderField(la_lifestyle.travel_detail_desc) %></span>\n </td>\n </tr>\n \n \n <tr class=\"width-100\" cellpadding=\"10\">\n <td colspan=\"3\" style=\"text-align:center;\" class=\"text-lg font-bold\">\n <h5>\u1795\u17D2\u1793\u17C2\u1780\u1791\u17B8 \u17E2: \u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u17A2\u17C6\u1796\u17B8\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784</h5>\n <h5>Part 2: INFORMATION ABOUT THE POLICY</h5>\n </td>\n </tr>\n \n <!-- Policy Info Labels -->\n <tr>\n <td style=\"width:45%;\">\n <p>\u1794\u17D2\u179A\u1797\u17C1\u1791\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784 \u1793\u17B7\u1784\u179A\u1799\u17C8\u1796\u17C1\u179B\u1792\u17B6\u1793\u17B6</p>\n <p>Type of Policy and Length of Cover</p>\n </td>\n <td>\n <p>\u1791\u17B9\u1780\u1794\u17D2\u179A\u17B6\u1780\u17CB\u178F\u17D2\u179A\u17BC\u179C\u1794\u17B6\u1793\u1792\u17B6\u1793\u17B6</p>\n <p>(\u178A\u17BB\u179B\u17D2\u179B\u17B6\u179A\u17A2\u17B6\u1798\u17C1\u179A\u17B7\u1780)</p>\n <p>Sum Assured (USD)</p>\n </td>\n <td>\n <p>\u1794\u17BB\u1796\u17D2\u179C\u179B\u17B6\u1797\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u178A\u17C2\u179B\u178F\u17D2\u179A\u17BC\u179C\u1794\u1784\u17CB</p>\n <p>(\u178A\u17BB\u179B\u17D2\u179B\u17B6\u179A\u17A2\u17B6\u1798\u17C1\u179A\u17B7\u1780)</p>\n <p>Premium Payable (USD)</p>\n </td>\n </tr>\n \n <!-- Policy Info Values -->\n <% policy_info.products.forEach(product=> { %>\n <tr class=\"text-md\">\n <td>\n <b>\n <%= product.product %>\n </b>\n </td>\n <td>\n <b>\n <%= product.sum_assured %>\n </b>\n </td>\n <td>\n <b>\n <%= product.premium %>\n </b>\n </td>\n </tr>\n <% }) %>\n \n <!-- Rider Details -->\n \n <tr>\n <td>\n <p>\n <span>\u17A2\u17C6\u1796\u17B8\u1782\u1798\u17D2\u179A\u17C4\u1784\u1794\u1793\u17D2\u1790\u17C2\u1798 / Details of Rider: </span>\n </p>\n <p class=\"text-md font-bold\">\n <%= policy_info.rider.product || 'N/A' %>\n </p>\n </td>\n <td class=\"text-md\">\n <b>\n <%= policy_info.rider.sum_assured || '-' %>\n </b>\n </td>\n <td class=\"text-md\">\n <b>\n <%= policy_info.rider.premium || '-' %>\n </b>\n </td>\n </tr>\n <!-- Total Premium -->\n <tr>\n <td colspan=\"2\" style=\"text-align:right;\">\n <p class=\"font-bold text-md\">\n \u1794\u17BB\u1796\u17D2\u179C\u179B\u17B6\u1797\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u179F\u179A\u17BB\u1794(\u178A\u17BB\u179B\u17D2\u179B\u17B6\u179A\u17A2\u17B6\u1798\u17C1\u179A\u17B7\u1780) / Total Premium (USD)\n </p>\n </td>\n <td class=\"text-md\">\n <b>\n <%= policy_info.total_premium %>\n </b>\n </td>\n </tr>\n </table>\n <!-- table 3 payment -->\n <table class=\"width-100 form-table\" style=\"margin-top:10px;\" cellpadding=\"10\">\n <tr>\n \n <!-- Premium Payment Label -->\n <td style=\"vertical-align:top;width:15%;\">\n <p>\u1794\u17BB\u1796\u17D2\u179C\u179B\u17B6\u1797\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u178A\u17C2\u179B\u178F\u17D2\u179A\u17BC\u179C\u1794\u1784\u17CB (\u1787\u17D2\u179A\u17BE\u179F\u179A\u17BE\u179F)</p>\n <p>Premium Payment (select):</p>\n </td>\n \n <!-- Premium Payment Options -->\n <td style=\"vertical-align:top;width:18%;\">\n \n <!-- Single Premium -->\n <div style=\"display:flex;align-items:flex-start;gap:6px;margin-top:4px;\">\n <input type=\"checkbox\" <%=policy_info.payment_mode==='Single' ? 'checked' : '' %>\n style=\"margin-top:3px;flex-shrink:0;\" />\n <span>\u1794\u17BB\u1796\u17D2\u179C\u179B\u17B6\u1797\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u1794\u1784\u17CB\u1798\u17BD\u1799\u179B\u17BE\u1780 / Single Premium</span>\n </div>\n \n <!-- Annually -->\n <div style=\"display:flex;align-items:flex-start;gap:6px;margin-top:6px;\">\n <input type=\"checkbox\" <%=policy_info.payment_mode==='Annually' ? 'checked' : '' %>\n style=\"margin-top:3px;flex-shrink:0;\" />\n <span>\u1794\u17D2\u179A\u1785\u17B6\u17C6\u1786\u17D2\u1793\u17B6\u17C6 / Annually</span>\n </div>\n \n <!-- Semi-Annually -->\n <div style=\"display:flex;align-items:flex-start;gap:6px;margin-top:6px;\">\n <input type=\"checkbox\" <%=policy_info.payment_mode==='Semi-Annually' ? 'checked' : '' %>\n style=\"margin-top:3px;flex-shrink:0;\" />\n <span>\u1794\u17D2\u179A\u1785\u17B6\u17C6\u1786\u1798\u17B6\u179F / Semi-Annually</span>\n </div>\n \n <!-- Quarterly -->\n <div style=\"display:flex;align-items:flex-start;gap:6px;margin-top:6px;\">\n <input type=\"checkbox\" <%=policy_info.payment_mode==='Quarterly' ? 'checked' : '' %>\n style=\"margin-top:3px;flex-shrink:0;\" />\n <span>\u1794\u17D2\u179A\u1785\u17B6\u17C6\u178F\u17D2\u179A\u17B8\u1798\u17B6\u179F / <span>Quarterly</span></span>\n </div>\n \n <!-- Monthly -->\n <div style=\"display:flex;align-items:flex-start;gap:6px;margin-top:6px;\">\n <input type=\"checkbox\" <%=policy_info.payment_mode==='Monthly' ? 'checked' : '' %>\n style=\"margin-top:3px;flex-shrink:0;\" />\n <span>\u1794\u17D2\u179A\u1785\u17B6\u17C6\u1781\u17C2 / Monthly</span>\n </div>\n \n </td>\n \n <!-- Method of Payment Label -->\n <td style=\"vertical-align:top;width:12.7%;\">\n <p>\u179A\u1794\u17C0\u1794\u1793\u17C3\u1780\u17B6\u179A\u1794\u1784\u17CB (\u1787\u17D2\u179A\u17BE\u179F\u179A\u17BE\u179F)</p>\n <p>Method of Payment (select)</p>\n </td>\n \n <!-- Method of Payment Options -->\n <td style=\"vertical-align:top;text-align:left;width:20%;\">\n \n <!-- Direct Debit -->\n <div style=\"display:flex;align-items:flex-start;gap:6px;margin-top:4px;\">\n <input type=\"checkbox\" <%=policy_info.payment_method==='Direct Debit' ? 'checked' : '' %>\n style=\"margin-top:3px;flex-shrink:0;\" />\n <span>\u17A5\u178E\u1796\u1793\u17D2\u1792\u1795\u17D2\u1791\u17B6\u179B\u17CB / <span>Direct Debit</span></span>\n </div>\n \n <!-- Bank Transfer -->\n <div style=\"display:flex;align-items:flex-start;gap:6px;margin-top:6px;\">\n <input type=\"checkbox\" <%=policy_info.payment_method==='Bank Transfer' ? 'checked' : '' %>\n style=\"margin-top:3px;flex-shrink:0;\" />\n <span>\u1795\u17D2\u1791\u17C1\u179A\u178F\u17B6\u1798\u179A\u1799\u17C8\u1792\u1793\u17B6\u1782\u17B6\u179A / <span>Bank Transfer</span></span>\n </div>\n \n <!-- Cheque -->\n <div style=\"display:flex;align-items:flex-start;gap:6px;margin-top:6px;\">\n <input type=\"checkbox\" <%=policy_info.payment_method==='Cheque' ? 'checked' : '' %>\n style=\"margin-top:3px;flex-shrink:0;\" />\n <span>\u1798\u17BC\u179B\u1794\u17D2\u1794\u1791\u17B6\u1793\u1794\u17D0\u178F\u17D2\u179A / <span>Cheque</span></span>\n </div>\n \n <!-- Cash -->\n <div style=\"display:flex;align-items:flex-start;gap:6px;margin-top:6px;\">\n <input type=\"checkbox\" <%=policy_info.payment_method==='Cash' ? 'checked' : '' %>\n style=\"margin-top:3px;flex-shrink:0;\" />\n <span>\u179F\u17B6\u1785\u17CB\u1794\u17D2\u179A\u17B6\u1780\u17CB / <span>Cash</span></span>\n </div>\n \n <!-- Credit Card -->\n <div style=\"display:flex;align-items:flex-start;gap:6px;margin-top:6px;\">\n <input type=\"checkbox\" <%=policy_info.payment_method==='Credit Card' ? 'checked' : '' %>\n style=\"margin-top:3px;flex-shrink:0;\" />\n <span>\u1794\u17D0\u178E\u17D2\u178E\u17A5\u178E\u1791\u17B6\u1793 / <span>Credit Card</span></span>\n </div>\n \n <!-- Other -->\n <div style=\"display:flex;align-items:flex-start;gap:6px;margin-top:6px;\">\n <input type=\"checkbox\" <%=policy_info.payment_method==='Other' ? 'checked' : '' %>\n style=\"margin-top:3px;flex-shrink:0;\" />\n <span>\u1795\u17D2\u179F\u17C1\u1784\u17D7 / Other</span>\n </div>\n \n </td>\n \n <!-- Direct Debit / Cheque / Credit Card Details -->\n <td colspan=\"4\" style=\"vertical-align:top;\">\n \n <!-- Direct Debit and Cheques -->\n <div>\n <p>\u17A5\u178E\u1796\u1793\u17D2\u1792\u1795\u17D2\u1791\u17B6\u179B\u17CB \u1793\u17B7\u1784\u1798\u17BC\u179B\u1794\u17D2\u1794\u1791\u17B6\u1793\u1794\u17D0\u178F\u17D2\u179A /</p>\n <p>Direct Debit and Cheques:</p>\n </div>\n \n <!-- Bank Name / Cheque No -->\n <div style=\"margin-top:4px;\">\n <p>\u179F\u17BC\u1798\u1795\u17D2\u178F\u179B\u17CB\u1788\u17D2\u1798\u17C4\u17C7\u1792\u1793\u17B6\u1782\u17B6\u179A \u1793\u17B7\u1784\u179F\u17B6\u1781\u17B6\u1792\u1793\u17B6\u1782\u17B6\u179A / \u179B\u17C1\u1781\u1798\u17BC\u179B\u1794\u17D2\u1794\u1791\u17B6\u1793\u1794\u17D0\u178F\u17D2\u179A</p>\n <p>Please provide bank name and branch / cheque no.</p>\n <%- policy_info.cheque_info ? '<p><u><b>' + policy_info.cheque_info + '</b></u></p>'\n : '<div style=\"border-bottom:1px solid #000;min-height:18px;width:100%;display:block;margin-top:4px;\"></div>'\n %>\n </div>\n \n <!-- Credit Card Number -->\n <div style=\"margin-top:4px;\">\n <p>\u1794\u17D0\u178E\u17D2\u178E\u17A5\u178E\u1791\u17B6\u1793 \u179F\u17BC\u1798\u1795\u17D2\u178F\u179B\u17CB\u179B\u17C1\u1781\u1794\u17D0\u178E\u17D2\u178E\u17A5\u178E\u1791\u17B6\u1793</p>\n <p>Credit card please provide card number</p>\n <%- policy_info.credit_card_info ? '<p><u><b>' + policy_info.credit_card_info + '</b></u></p>'\n : '<div style=\"border-bottom:1px solid #000;min-height:18px;width:100%;display:block;margin-top:4px;\"></div>'\n %>\n </div>\n \n <!-- Card Type -->\n <div style=\"display:flex;align-items:center;gap:12px;margin-top:4px;flex-wrap:wrap;\">\n <div style=\"display:flex;align-items:center;gap:6px;\">\n <input type=\"checkbox\" <%=policy_info.credit_card_type==='Visa' ? 'checked' : '' %>\n style=\"flex-shrink:0;\"\n />\n <span>Visa</span>\n </div>\n <div style=\"display:flex;align-items:center;gap:6px;\">\n <input type=\"checkbox\" <%=policy_info.credit_card_type==='Master' ? 'checked' : '' %>\n style=\"flex-shrink:0;\"\n />\n <span>Master</span>\n </div>\n <div style=\"display:flex;align-items:center;gap:6px;\">\n <input type=\"checkbox\" <%=policy_info.credit_card_type==='American Express' ? 'checked' : '' %>\n style=\"flex-shrink:0;\" />\n <span>American Express</span>\n </div>\n </div>\n \n <!-- Expiry Date -->\n <div style=\"margin-top:4px;\">\n <span>\u1790\u17D2\u1784\u17C3\u1795\u17BB\u178F\u1780\u17C6\u178E\u178F\u17CB /</span>\n <span> Expiry Date:</span>\n <%- policy_info.credit_card_expiry_date ? '<p><u><b>' + policy_info.credit_card_expiry_date + '</b></u></p>'\n : '<div style=\"border-bottom:1px solid #000;min-height:18px;width:100%;display:block;margin-top:4px;\"></div>'\n %>\n </div>\n \n <!-- Other Method -->\n <div style=\"margin-top:4px;\">\n <span>\u1795\u17D2\u179F\u17C1\u1784\u1791\u17C0\u178F \u179F\u17BC\u1798\u1794\u1789\u17D2\u1787\u17B6\u1780\u17CB\u179C\u17B7\u1792\u17B8\u1794\u1784\u17CB\u1794\u17D2\u179A\u17B6\u1780\u17CB /</span>\n <span> Other indicate method of payment:</span>\n <%- policy_info.other_payment_method_desc ? '<p><u><b>' + policy_info.other_payment_method_desc + '</b></u></p>'\n : '<div style=\"border-bottom:1px solid #000;min-height:18px;width:100%;display:block;margin-top:4px;\"></div>'\n %>\n </div>\n </td>\n </tr>\n </table>\n <!-- page break -->\n <div style=\"page-break-after: always;\"></div>\n \n <!-- table 4 beneficiaries -->\n <table class=\"width-100 form-table\" style=\"margin-top:10px;\" cellpadding=\"10\">\n <colgroup>\n <col style=\"width: 25%;\" />\n <col style=\"width: 5%;\" />\n <col style=\"width: 20%;\" />\n <col style=\"width: 35%;\" />\n <col style=\"width: 15%;\" />\n </colgroup>\n \n <tr class=\"width-100\" cellpadding=\"10\">\n <td colspan=\"5\" style=\"text-align:center;\" class=\"text-lg font-bold\">\n <h5>\u1795\u17D2\u1793\u17C2\u1780\u1791\u17B8\u17E3: \u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u179A\u1794\u179F\u17CB\u17A2\u17D2\u1793\u1780\u1791\u1791\u17BD\u179B\u1795\u179B</h5>\n <h5>Part 3: BENEFICIARIES DETAILS</h5>\n </td>\n </tr>\n \n <tr class=\"text-start\">\n <td style=\"vertical-align: top;\">\n <p>\n \u1788\u17D2\u1798\u17C4\u17C7\u1796\u17C1\u1789\u179A\u1794\u179F\u17CB\u17A2\u17D2\u1793\u1780\u1791\u1791\u17BD\u179B\u1795\u179B\u1787\u17B6\u1797\u17B6\u179F\u17B6\u1781\u17D2\u1798\u17C2\u179A \u1793\u17B7\u1784\u17A2\u1784\u17CB\u1782\u17D2\u179B\u17C1\u179F\n </p>\n <p>\n Beneficiary's Full Name in Khmer and English\n </p>\n </td>\n \n <td style=\"vertical-align: top;\">\n <p>\u17A2\u17B6\u1799\u17BB</p>\n <p>Age</p>\n </td>\n \n <td style=\"vertical-align: top;\">\n <p>\u1791\u17C6\u1793\u17B6\u1780\u17CB\u1791\u17C6\u1793\u1784</p>\n <p>Relationship</p>\n </td>\n \n <td style=\"vertical-align: top;\">\n <p>\n \u179B\u17C1\u1781\u17A2\u178F\u17D2\u178F\u179F\u1789\u17D2\u1789\u17B6\u178E\u1794\u17D0\u178E\u17D2\u178E/\u179B\u17B7\u1781\u17B7\u178F\u1786\u17D2\u179B\u1784\u178A\u17C2\u1793/\u179F\u17C6\u1794\u17BB\u178F\u17D2\u179A\u1780\u17C6\u178E\u17BE\u178F\n </p>\n <p>\n ID, Passport, Birth Certificate Number\n </p>\n </td>\n \n <td style=\"vertical-align: top;\">\n <p>% \u1793\u17C3\u1780\u17B6\u179A\u1794\u17C2\u1784\u1785\u17C2\u1780</p>\n <p>% of Share</p>\n </td>\n </tr>\n \n <% beneficiaries.forEach(benefactor=> { %>\n <tr>\n <td>\n <p> <span><b>\n <%= benefactor.full_name %>\n </b></span> </p>\n </td>\n <td>\n <p> <span><b>\n <%= benefactor.age %>\n </b></span> </p>\n </td>\n <td>\n <p> <span><b>\n <%= benefactor.relationship %>\n </b></span> </p>\n </td>\n <td>\n <p> <span><b>\n <%= benefactor.identifier_and_birth_info %>\n </b></span> </p>\n </td>\n <td>\n <p> <span><b>\n <%= benefactor.percentage %>\n </b></span> </p>\n </td>\n </tr>\n <% }) %>\n \n <tr>\n <td colspan=\"4\" style=\"text-align:right\">\n <span>% \u179F\u179A\u17BB\u1794 /</span>\n <span>Total %</span>\n </td>\n <td> <b>100%</b> </td>\n </tr>\n \n <tr>\n <td colspan=\"5\">\n <p>\n <span>\n \u1780\u17C6\u178E\u178F\u17CB\u179F\u1798\u17D2\u1782\u17B6\u179B\u17CB\u17D6 \u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17BE\u1797\u17B6\u1782\u179A\u1799\u1798\u17B7\u1793\u1794\u17B6\u1793\u1794\u1789\u17D2\u1787\u17B6\u1780\u17CB\u1785\u17C6\u1793\u17BD\u1793\u1791\u17B9\u1780\u1794\u17D2\u179A\u17B6\u1780\u17CB\u1793\u17B9\u1784\u178F\u17D2\u179A\u17BC\u179C\u1785\u17C2\u1780\u179F\u17D2\u1798\u17BE\u17D7\u1782\u17D2\u1793\u17B6 /\n </span>\n <span>\n Note: If the percentage is not specified the amount will be shared equally\n </span>\n </p>\n </td>\n </tr>\n </table>\n <!-- table 5 existing insurance -->\n <table class=\"width-100 form-table\" style=\"margin-top:10px;\" cellpadding=\"10\">\n <colgroup>\n <col style=\"width: 60%;\" />\n <col style=\"width: 20%;\" />\n <col style=\"width: 20%;\" />\n </colgroup>\n <tr class=\"width-100\" cellpadding=\"10\">\n <td colspan=\"3\" style=\"text-align:center;\" class=\"text-lg font-bold\">\n <h5>\u179F\u17C1\u1785\u1780\u17D2\u178A\u17B8\u1794\u17D2\u179A\u1780\u17B6\u179F\u17A2\u17C6\u1796\u17B8\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u178A\u17C2\u179B\u1798\u17B6\u1793</h5>\n <h5>DECLARATION OF ANY EXISTING INSURANCE POLICIES</h5>\n </td>\n </tr>\n \n <tr>\n <td colspan=\"3\">\n <p class=\"mb-2\">\n <span>\n \u178F\u17BE\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u1798\u17B6\u1793\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u178A\u17C2\u179A\u17AC\u1791\u17C1 / Do you have any existing insurance policies?\n </span>\n <%- yesNoCheckbox(existing_insurance_info.has_existing_insurance) %>\n </p>\n <p class=\"mt-2\">\n <span>\n \u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17BE\u1798\u17B6\u1793 \u179F\u17BC\u1798\u1795\u17D2\u178A\u179B\u17CB\u1796\u17D0\u178F\u17CD\u1798\u17B6\u1793\u178A\u17BC\u1785\u1781\u17B6\u1784\u1780\u17D2\u179A\u17C4\u1798 / If yes, please provide the following information:\n <!-- <div class=\"form-field-line\"> -->\n </span>\n </p>\n </td>\n </tr>\n \n <tr>\n <td style=\"vertical-align: top;\">\n <p>\n \u1788\u17D2\u1798\u17C4\u17C7\u179A\u1794\u179F\u17CB\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\n </p>\n <p>\n Name of Insurance Company\n </p>\n </td>\n <td style=\"vertical-align: top;\">\n <p>\n \u1794\u17D2\u179A\u1797\u17C1\u1791\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u178A\u17C2\u179B\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u1798\u17B6\u1793\n </p>\n <p>\n Type of Policy You Currently Have\n </p>\n </td>\n <td style=\"vertical-align: top;\">\n <p>\n \u1791\u17B9\u1780\u1794\u17D2\u179A\u17B6\u1780\u17CB\u178F\u17D2\u179A\u17BC\u179C\u1794\u17B6\u1793\u1792\u17B6\u1793\u17B6\u179F\u179A\u17BB\u1794\n </p>\n <p>\n The Total Amount Insured (USD)\n </p>\n </td>\n </tr>\n \n <% existing_insurance_info.existing_policy_info.forEach(exist_pilicy=> { %>\n <tr>\n <td><b>\n <%= exist_pilicy.insurance_company %>\n </b></td>\n <td><b>\n <%= exist_pilicy.type_of_policy %>\n </b></td>\n <td><b>\n <%= exist_pilicy.sum_assured %>\n </b></td>\n </tr>\n <% }) %>\n \n <% if (existing_insurance_info.existing_policy_info.length===0) { %>\n <tr>\n <td class=\"height-25\">&nbsp;</td>\n <td>&nbsp;</td>\n <td>&nbsp;</td>\n </tr>\n <tr>\n <td class=\"height-25\">&nbsp;</td>\n <td>&nbsp;</td>\n <td>&nbsp;</td>\n </tr>\n <% } %>\n \n </tbody>\n </table>\n <!-- iMPORTANT Remark-->\n <h4 class=\"font-bold text-lg mt-5 underline\">\u1785\u17C6\u178E\u17B6\u17C6\u200B / IMPORTANT \u17D6</h4>\n \n <div class=\"my-2 space-y-2\">\n <p>\n \u1799\u17BE\u1784\u1781\u17D2\u1789\u17BB\u17C6\u179F\u17BC\u1798\u178E\u17C2\u1793\u17B6\u17C6\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u1798\u17B7\u1793\u1782\u17BD\u179A\u1795\u17D2\u179B\u17B6\u179F\u17CB\u1794\u17D2\u178F\u17BC\u179A\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u17A2\u17B6\u1799\u17BB\u1787\u17B8\u179C\u17B7\u178F\u178A\u17C2\u179B\u1798\u17B6\u1793\u179F\u17D2\u179A\u17B6\u1794\u17CB\u1787\u17B6\u1798\u17BD\u1799\u1793\u17B9\u1784\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u1790\u17D2\u1798\u17B8\u17D4\n \u1782\u17BB\u178E\u179C\u17B7\u1794\u178F\u17D2\u178F\u17B7\u1798\u17BD\u1799\u1785\u17C6\u1793\u17BD\u1793\u1782\u17BA\u17D6\n </p>\n <p>\n We advise you not to replace an existing life insurance policy with a new one. Some disadvantages are:\n </p>\n \n <ol style=\"list-style-type: decimal; padding-left: 30px; margin: 0;\">\n <li style=\"margin-bottom: 6px;\">\n \u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u17A2\u17B6\u1785\u1793\u17B9\u1784\u1798\u17B7\u1793\u1791\u1791\u17BD\u179B\u1794\u17B6\u1793\u1780\u17B6\u179A\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u178F\u17B6\u1798\u179B\u1780\u17D2\u1781\u1781\u178E\u17D2\u178C\u1791\u17BC\u1791\u17C5 /\n You may not be insurable on standard terms\n </li>\n \n <li style=\"margin-bottom: 6px;\">\n \u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u17A2\u17B6\u1785\u1793\u17B9\u1784\u178F\u17D2\u179A\u17BC\u179C\u1794\u1784\u17CB\u1794\u17BB\u1796\u17D2\u179C\u179B\u17B6\u1797\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u1781\u17D2\u1796\u179F\u17CB\u1787\u17B6\u1784\u1794\u1785\u17D2\u1785\u17BB\u1794\u17D2\u1794\u1793\u17D2\u1793\u178A\u17C4\u1799\u179F\u17B6\u179A\u1796\u17C1\u179B\u1793\u17C1\u17C7\u17A2\u17D2\u1793\u1780\u1798\u17B6\u1793\u17A2\u17B6\u1799\u17BB\u1785\u17D2\u179A\u17BE\u1793\u1787\u17B6\u1784\u1798\u17BB\u1793 /\n You may have to pay a higher premium as you are now older\n </li>\n \n <li>\n \u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u17A2\u17B6\u1785\u1793\u17B9\u1784\u1794\u17B6\u178F\u17CB\u1794\u1784\u17CB\u1780\u17C6\u178E\u17BE\u1793\u17A2\u178F\u17D2\u1790\u1794\u17D2\u179A\u1799\u17C4\u1787\u1793\u17CD\u17A0\u17B7\u179A\u1789\u17D2\u1789\u179C\u178F\u17D2\u1790\u17BB\u178A\u17C2\u179B\u1798\u17B6\u1793\u1780\u17D2\u1793\u17BB\u1784\u1786\u17D2\u1793\u17B6\u17C6\u1780\u1793\u17D2\u179B\u1784\u1798\u1780 /\n You may lose financial benefits built up over the years\n </li>\n </ol>\n <p>\n \u179F\u17BC\u1798\u1796\u17B7\u1782\u17D2\u179A\u17C4\u17C7\u1787\u17B6\u1798\u17BD\u1799\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u1794\u1785\u17D2\u1785\u17BB\u1794\u17D2\u1794\u1793\u17D2\u1793\u179A\u1794\u179F\u17CB\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780 \u1798\u17BB\u1793\u1793\u17B9\u1784\u1792\u17D2\u179C\u17BE\u1780\u17B6\u179A\u179F\u1798\u17D2\u179A\u17C1\u1785\u1785\u17B7\u178F\u17D2\u178F\u17D4\n \u179F\u17BC\u1798\u1792\u17D2\u179C\u17BE\u1780\u17B6\u179A\u1794\u17D2\u179A\u17C0\u1794\u1792\u17C0\u1794\u178A\u17C4\u1799\u1794\u17D2\u179A\u17BB\u1784\u1794\u17D2\u179A\u1799\u17D0\u178F\u17D2\u1793\u178A\u17BE\u1798\u17D2\u1794\u17B8\u1794\u17D2\u179A\u17B6\u1780\u178A\u1790\u17B6\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u1780\u17C6\u1796\u17BB\u1784\u1792\u17D2\u179C\u17BE\u1780\u17B6\u179A\n \u179F\u1798\u17D2\u179A\u17C1\u1785\u1785\u17B7\u178F\u17D2\u178F\u178A\u17C2\u179B\u179B\u17D2\u17A2\u1794\u17C6\u1795\u17BB\u178F\u179F\u1798\u17D2\u179A\u17B6\u1794\u17CB\u17A2\u178F\u17D2\u1790\u1794\u17D2\u179A\u1799\u17C4\u1787\u1793\u17CD\u179A\u1794\u179F\u17CB\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u17D4\n </p>\n <p>\n Please consult your current insurer before making a final decision. Make a careful comparison so that\n you\n can be sure you are making a decision that is in your best interest.\n </p>\n \n <p>\n \u178F\u17BE\u1798\u17B6\u1793\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u178E\u17B6\u1798\u17BD\u1799\u178A\u17C2\u179B\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u1780\u17C6\u1796\u17BB\u1784\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u178A\u17BE\u1798\u17D2\u1794\u17B8\u1787\u17C6\u1793\u17BD\u179F\n \u17AC\u1798\u17B6\u1793\u1794\u17C6\u178E\u1784\u1787\u17C6\u1793\u17BD\u179F\u178A\u17BC\u1785\u1794\u17B6\u1793\u179A\u17C0\u1794\u179A\u17B6\u1794\u17CB\u1781\u17B6\u1784\u179B\u17BE\u178A\u17C2\u179A\u17AC\u1791\u17C1?\n </p>\n <p>\n Is the insurance you are applying for to replace, or intended to replace, any of the policies listed\n above?\n </p>\n <%- yesNoCheckbox(existing_insurance_info.is_intended_to_replace) %>\n \n <p>\u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17BE\u1798\u17B6\u1793 \u1798\u17BD\u1799\u178E\u17B6? / If yes, which one?\n </p>\n \n <%- renderField(existing_insurance_info.replacement_detail_desc ) %>\n \n <p>\n <span>\u1799\u17BE\u1784\u1781\u17D2\u1789\u17BB\u17C6\u178F\u17D2\u179A\u17BC\u179C\u1780\u17B6\u179A\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u1793\u17C1\u17C7\u178A\u17BE\u1798\u17D2\u1794\u17B8\u1795\u17D2\u178F\u179B\u17CB\u178A\u17C6\u178E\u17B9\u1784\u178A\u179B\u17CB\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u1794\u1785\u17D2\u1785\u17BB\u1794\u17D2\u1794\u1793\u17D2\u1793\u179A\u1794\u179F\u17CB\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780(\u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17BE\u1798\u17B6\u1793)\u1790\u17B6\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u17A2\u17B6\u1785\u1793\u17B9\u1784\u179F\u1798\u17D2\u179A\u17C1\u1785\u1785\u17B7\u178F\u17D2\u178F\u1795\u17D2\u179B\u17B6\u179F\u17CB\u1794\u17D2\u178F\u17BC\u179A\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u17D4</span>\n <span>\n We need this information as we are required to inform your existing insurer-if you have one-that\n you\n may be\n replacing\n the policy.\n </span>\n </p>\n <span>\n \u178F\u17BE\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u1798\u17B6\u1793\u1780\u17B6\u179A\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\n \u17AC\u1796\u17B6\u1780\u17D2\u1799\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u1780\u17B6\u179A\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u17A2\u17B6\u1799\u17BB\u1787\u17B8\u179C\u17B7\u178F\u178E\u17B6\u1798\u17BD\u1799\u178A\u17C2\u179B\u178F\u17D2\u179A\u17BC\u179C\u1794\u17B6\u1793\u1794\u178A\u17B7\u179F\u17C1\u1792 \u1796\u1793\u17D2\u1799\u17B6\u179A\u1796\u17C1\u179B\n \u17AC\u1791\u1791\u17BD\u179B\u1799\u1780\u1780\u17D2\u179A\u17C4\u1798\u179B\u1780\u17D2\u1781\u1781\u178E\u17D2\u178C\u1796\u17B7\u179F\u17C1\u179F\u178A\u17C4\u1799\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u178E\u17B6\u1798\u17BD\u1799\u1795\u17D2\u179F\u17C1\u1784\u1791\u17C0\u178F\u178A\u17C2\u179A\u17AC\u1791\u17C1?\n \u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17BE\u1798\u17B6\u1793\u179F\u17BC\u1798\u1795\u17D2\u178F\u179B\u17CB\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u179B\u1798\u17D2\u17A2\u17B7\u178F\u178A\u17BC\u1785\u1781\u17B6\u1784\u1780\u17D2\u179A\u17C4\u1798\n </span>\n \n <%- yesNoCheckbox(existing_insurance_info.is_rejected_by_other_insurer) %>\n \n <p>\n Has any proposal or application for a Life Insurance policy of any kind ever been refused,\n postponed,\n or accepted at special terms by any other insurer? If yes, please provide details below:\n </p>\n </div>\n \n <table style=\"width:100%; table-layout:fixed; border-collapse:collapse;\" cellpadding=\"10\" class=\"form-table\">\n <colgroup>\n <col style=\"width: 25%;\" />\n <col style=\"width: 25%;\" />\n <col style=\"width: 25%;\" />\n <col style=\"width: 25%;\" />\n </colgroup>\n <tr>\n <td>\n <p>\u1788\u17D2\u1798\u17C4\u17C7\u179A\u1794\u179F\u17CB\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784</p>\n <p>Name of Insurance Company</p>\n </td>\n \n <td class=\"td-width-100\">\n <p>\n <b>\n <%= existing_insurance_info.rejected_insurance_company %>\n </b>\n </p>\n </td>\n \n <td>\n <p>\u1794\u17D2\u179A\u1797\u17C1\u1791\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784</p>\n <p>Type of Policy</p>\n </td>\n \n <td class=\"td-width-100\">\n <p>\n <b>\n <%= existing_insurance_info.rejected_policy_type %>\n </b>\n </p>\n </td>\n </tr>\n \n <tr>\n <td>\n <span>\u1798\u17BC\u179B\u17A0\u17C1\u178F\u17BB </span>\n <span>Reasons Given</span>\n </td>\n \n <td colspan=\"3\">\n <p>\n <b>\n <%= existing_insurance_info.rejected_reason %>\n </b>\n </p>\n </td>\n </tr>\n </table>\n <!-- page break -->\n <div style=\"page-break-after: always;\"></div>\n \n <!-- Part 7 Health Questions-->\n <table class=\"width-100 form-table\" style=\"margin-top:10px;\" cellpadding=\"10\">\n \n <tr class=\"width-100\" cellpadding=\"10\">\n <td colspan=\"3\" style=\"text-align:center;\" class=\"text-lg font-bold\">\n <h5>\u1795\u17D2\u1793\u17C2\u1780\u1791\u17B8\u17E4: \u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u1796\u17B6\u1780\u17CB\u1796\u17D0\u1793\u17D2\u1792\u1793\u17B9\u1784\u179F\u17BB\u1781\u1797\u17B6\u1796</h5>\n <h5>Part 4: HEALTH-RELATED QUESTIONS</h5>\n </td>\n </tr>\n \n <tr>\n <td style=\"width:35%;\" class=\"align-top\">\n <table style=\"border-collapse: collapse; width: 100%; border: none;\">\n <colgroup>\n <col style=\"width: 40%;\" />\n <col style=\"width: 60%;\" />\n </colgroup>\n <tr>\n <td style=\"white-space: nowrap; border: none;\">\n <span>\u1780\u1798\u17D2\u1796\u179F\u17CB / Height:</span>\n </td>\n <td style=\"border: none;\">\n <b>\n <u>\n <span class=\"font-eng font-bold\">\n <%= health_info.height %> \u179F.\u1798 / cm\n </span>\n </u>\n </b>\n </td>\n </tr>\n <tr>\n <td style=\"white-space: nowrap; border: none;\">\n <span>\u1791\u1798\u17D2\u1784\u1793\u17CB / Weight:</span>\n </td>\n <td style=\"border: none;\">\n <b><u>\n <span class=\"font-eng font-bold\">\n <%= health_info.weight %>\n </span>\n <span> \u1782.\u1780\u17D2\u179A / kg</span>\n </u></b>\n </td>\n </tr>\n </table>\n </td>\n \n <td class=\"align-top\">\n <p>\n <span>\n \u178F\u17BE\u1798\u17B6\u1793\u1780\u17B6\u179A\u1795\u17D2\u179B\u17B6\u179F\u17CB\u1794\u17D2\u178F\u17BC\u179A\u1791\u1798\u17D2\u1784\u1793\u17CB\u1780\u17D2\u1793\u17BB\u1784\u1780\u17C6\u17A1\u17BB\u1784\u1796\u17C1\u179B \u17E6 \u1781\u17C2\u17AC\u1791\u17C1? / Any weight changes during the past 6 month?\n </span>\n <%- yesNoCheckbox( health_info.is_weight_changed) %>\n </p>\n </td>\n </tr>\n \n <tr>\n <td class=\"align-top\">\n <p>\n \u178F\u17BE\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u1796\u17B7\u179F\u17B6\u179A\u1794\u17B6\u179A\u17B8\u178A\u17C2\u179A\u17AC\u1791\u17C1? / Do you smoke?\n </p>\n <%- yesNoCheckbox(health_info.is_smoke) %>\n </td>\n \n <td class=\"align-top\">\n <p>\n \u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17BE\u1798\u17B6\u1793 \u178F\u17BE\u1794\u17C9\u17BB\u1793\u17D2\u1798\u17B6\u1793\u178A\u17BE\u1798\u1780\u17D2\u1793\u17BB\u1784\u1798\u17BD\u1799\u1790\u17D2\u1784\u17C3? / If yes, How many cigarettes per day?\n </p>\n <%- renderField(health_info.smoke_detail) %>\n </td>\n </tr>\n \n <tr>\n <td class=\"align-top\">\n <p>\n Have you ever taken any kind of addictive substance/drugs?\n \u178F\u17BE\u17A2\u17D2\u1793\u1780\u1792\u17D2\u179B\u17B6\u1794\u17CB\u1794\u17D2\u179A\u17BE\u1794\u17D2\u179A\u17B6\u179F\u17CB\u179F\u17B6\u179A\u1792\u17B6\u178F\u17BB\u1789\u17C0\u1793 \u17AC\u1790\u17D2\u1793\u17B6\u17C6\u1789\u17C0\u1793\u178A\u17C2\u179A\u17AC\u1791\u17C1? /\n </p>\n <%- yesNoCheckbox(health_info.is_drug_or_substance) %>\n </td>\n \n <td class=\"align-top space-y-3\">\n <p>\n If yes, please state:\n \u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17BE\u1798\u17B6\u1793 \u179F\u17BC\u1798\u1794\u1789\u17D2\u1787\u17B6\u1780\u17CB\u178A\u17BC\u1785\u1781\u17B6\u1784\u1780\u17D2\u179A\u17C4\u1798 /\n </p>\n \n <p>\n <span>\n (\u1780). \u1794\u17D2\u179A\u1797\u17C1\u1791\u1790\u17D2\u1793\u17B6\u17C6 / Type of drug\n <%- renderField(health_info.drug_type) %>\n </span>\n </p>\n \n <p>\n <span>\n (\u1781). \u179A\u1799\u17C8\u1796\u17C1\u179B\u1794\u17D2\u179A\u17BE\u1794\u17D2\u179A\u17B6\u179F\u17CB / For how long?\n <%- renderField(health_info.drug_duration) %>\n </span>\n </p>\n \n <p>\n <span>\n (\u1782). \u178F\u17BE\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u1794\u17B6\u1793\u1788\u1794\u17CB\u1794\u17D2\u179A\u17BE\u1794\u17D2\u179A\u17B6\u179F\u17CB\u17A0\u17BE\u1799\u17AC\u1793\u17C5? / Have you stopped?\n <%- renderField(health_info.drug_stopped) %>\n </span>\n </p>\n \n </td>\n </tr>\n \n <tr>\n <td class=\"align-top\">\n <p>\n \u178F\u17BE\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u1796\u17B7\u179F\u17B6\u179A\u1782\u17D2\u179A\u17BF\u1784\u179F\u17D2\u179A\u179C\u17B9\u1784\u178A\u17C2\u179A\u17AC\u1791\u17C1? / Do you drink alcohol?\n </p>\n <%- yesNoCheckbox(health_info.is_alcohol) %>\n </td>\n \n <td>\n <p>\n \u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17BE\u1798\u17B6\u1793 \u178F\u17BE\u1789\u17B9\u1780\u1789\u17B6\u1794\u17CB\u178A\u17C2\u179A\u17AC\u1791\u17C1? / If yes, how often?\n </p>\n <p>\n \u179F\u17BC\u1798\u1794\u1789\u17D2\u1787\u17B6\u1780\u17CB\u1794\u179A\u17B7\u1798\u17B6\u178E\u178A\u17C2\u179B\u1794\u17B6\u1793\u1796\u17B7\u179F\u17B6\u179A\u1780\u17D2\u1793\u17BB\u1784\u1798\u17BD\u1799\u179F\u1794\u17D2\u178F\u17B6\u17A0\u17CD / Please specify amount of drink per week.\n <%- renderField(health_info.alcohol_detail) %>\n </p>\n </td>\n </tr>\n </table>\n <div class=\"space-y-2 my-3\">\n <p class=\"text-justify\">\u178F\u17BE\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u1798\u17B6\u1793\u17AA\u1796\u17BB\u1780\u1798\u17D2\u178F\u17B6\u1799 \u17AC\u1794\u1784\u1794\u17D2\u17A2\u17BC\u1793\u1794\u1784\u17D2\u1780\u17BE\u178F \u1798\u17B6\u1793\u1787\u17C6\u1784\u17BA \u17AC\u1791\u1791\u17BD\u179B\u1798\u179A\u178E\u1797\u17B6\u1796\u178A\u17C4\u1799\u179F\u17B6\u179A\u17D6 \u1787\u17C6\u1784\u17BA\u179C\u1784\u17D2\u179C\u17C1\u1784\n (Alzheimer's\n disease) \u1787\u17C6\u1784\u17BA\u1798\u17A0\u17B6\u179A\u17B8\u1780\n (Cancer) \u1787\u17C6\u1784\u17BA\u1787\u17B6\u179B\u17B7\u1780\u17B6\u1798\u17A0\u17B6\u179A\u17B8\u1780\u1798\u17B7\u1793\u1791\u17B6\u1793\u17CB\u179A\u17B6\u179B\u178A\u17B6\u179B (Carcinoma in situ) \u1787\u17C6\u1784\u17BA\u1795\u17D2\u179B\u17BC\u179C\u1785\u17B7\u178F\u17D2\u178F (Mental illness)\n \u1787\u17C6\u1784\u17BA\u1791\u17B9\u1780\u1793\u17C4\u1798\u1795\u17D2\u17A2\u17C2\u1798\n (Diabetes) \u1787\u17C6\u1784\u17BA\u178F\u1798\u17D2\u179A\u1784\u1793\u17C4\u1798 (polycystic kidney disease) \u1787\u17C6\u1784\u17BA\u178A\u17B6\u1785\u17CB\u179F\u179A\u179F\u17C3\u1788\u17B6\u1798\u1781\u17BD\u179A\u1780\u17D2\u1794\u17B6\u179B (Stroke)\n \u1780\u17B6\u179A\u17A1\u17BE\u1784\u179F\u1798\u17D2\u1796\u17B6\u1792\u1788\u17B6\u1798\u1781\u17D2\u1796\u179F\u17CB\n (High\n blood pressure) \u1787\u17C6\u1784\u17BA\u1794\u17C1\u17C7\u178A\u17BC\u1784 (Heart Disease) \u17AC\u1787\u17C6\u1784\u17BA\u178F\u17C6\u178E\u1796\u17BC\u1787\u178A\u1791\u17C3\u1791\u17C0\u178F (Hereditary disease) \u178A\u17C2\u179A\u17AC\u1791\u17C1?</p>\n \n <p class=\"text-justify\">Have any of your biological parents or siblings been diagnosed with or passed\n away as\n a\n result\n of: Alzheimer's\n disease, cancer, carcinoma in situ, mental illness, diabetes, polycystic kidney disease, stroke, high\n blood\n pressure, heart disease, or any other hereditary disease?</p>\n \n <%- yesNoCheckbox(health_info.is_hereditary_disease) %>\n \n <p class=\"mb-3\">\u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17BE\u1798\u17B6\u1793 \u179F\u17BC\u1798\u1795\u17D2\u178A\u179B\u17CB\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u179B\u1798\u17D2\u17A2\u17B7\u178F\u178A\u17BC\u1785\u1781\u17B6\u1784\u1780\u17D2\u179A\u17C4\u1798 / If yes, please provide details below:\n </p>\n </div>\n \n <table style=\"width:100%; table-layout:fixed; border-collapse:collapse;\" cellpadding=\"10\" class=\"form-table\">\n <colgroup>\n <col style=\"width: 25%;\" />\n <col style=\"width: 25%;\" />\n <col style=\"width: 25%;\" />\n <col style=\"width: 25%;\" />\n </colgroup>\n <tr>\n <td>\n <p>\u1788\u17D2\u1798\u17C4\u17C7\u179A\u1794\u179F\u17CB\u179F\u17B6\u1785\u17CB\u1789\u17B6\u178F\u17B7</p>\n <p>Name of Relative</p>\n </td>\n \n <td>\n <p>\u1791\u17C6\u1793\u17B6\u1780\u17CB\u1791\u17C6\u1793\u1784\u1787\u17B6\u1798\u17BD\u1799\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780</p>\n <p>Relationship to you</p>\n </td>\n \n <td>\n <p>\u1787\u1798\u17D2\u1784\u17BA</p>\n <p>Illness</p>\n </td>\n \n <td>\n <p>\u179A\u179F\u17CB\u1793\u17C5 \u17AC\u1791\u1791\u17BD\u179B\u1798\u179A\u178E\u17C8\u1797\u17B6\u1796</p>\n <p>Living or Deceased?</p>\n </td>\n </tr>\n \n <% health_info.hereditary_relative_info.forEach(hereditary=> { %>\n <tr>\n <td><b>\n <%= hereditary.full_name %>\n </b></td>\n <td><b>\n <%= hereditary.relationship %>\n </b></td>\n <td><b>\n <%= hereditary.illness %>\n </b></td>\n <td><b>\n <%= hereditary.living_or_deceased %>\n </b></td>\n </tr>\n <% }) %>\n \n <% if (health_info.hereditary_relative_info.length===0) { %>\n <tr>\n <td class=\"height-25\">&nbsp;</td>\n <td>&nbsp;</td>\n <td>&nbsp;</td>\n <td>&nbsp;</td>\n </tr>\n <% } %>\n </table>\n </div>\n \n <div id=\"questions-source\">\n <!-- Additional Questions-->\n <table class=\"table w-full table-fixed border-collapse form-table\" cellpadding=\"10\">\n \n <colgroup>\n <col style=\"width: 45%;\" />\n <col style=\"width: 10%;\" />\n <col style=\"width: 10%;\" />\n <col style=\"width: 35%;\" />\n </colgroup>\n \n <!-- Header -->\n <tr class=\"width-100\" cellpadding=\"10\">\n <td colspan=\"4\" style=\"text-align:center;\" class=\"text-lg font-bold\">\n <h5>\u179F\u17C6\u178E\u17BD\u179A\u1794\u1793\u17D2\u1790\u17C2\u1798</h5>\n <h5>ADDITIONAL QUESTIONS</h5>\n </td>\n </tr>\n \n <!-- Sub-header -->\n <tr>\n <td rowspan=\"2\" class=\"align-top\">\n <p>\n 1.\u178F\u17BE\u179B\u17C4\u1780\u17A2\u17D2\u1793\u1780\u1792\u17D2\u179B\u17B6\u1794\u17CB\u1794\u17B6\u1793\u1791\u1791\u17BD\u179B\u1780\u17B6\u179A\u1796\u17D2\u1799\u17B6\u1794\u17B6\u179B\u1787\u17C6\u1784\u17BA \u17AC\u1798\u17B6\u1793\u179A\u17C4\u1782\u179F\u1789\u17D2\u1789\u17B6\u178E\u1798\u17BD\u1799\u178A\u17BC\u1785\u1781\u17B6\u1784\u1780\u17D2\u179A\u17C4\u1798\u178A\u17C2\u179A\u17AC\u1791\u17C1?\n </p>\n <p>\n Have you ever had or treated for any of the following conditions or symptoms?\n </p>\n </td>\n <td colspan=\"2\" class=\"text-center align-top\">\n <span>\u179F\u17BC\u1798\u1782\u17BC\u179F / Please Tick</span>\n </td>\n <td rowspan=\"2\" class=\"align-top\">\n <p>\n \u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17BE\u1798\u17B6\u1793 \u179F\u17BC\u1798\u1795\u17D2\u178F\u179B\u17CB\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u179B\u1798\u17D2\u17A2\u17B7\u178F\u1781\u17B6\u1784\u1780\u17D2\u179A\u17C4\u1798\n </p>\n <p>\n If yes, please provide more details:\n </p>\n </td>\n </tr>\n \n <!-- Question 1 -->\n <tr>\n <td style=\"width:10%; text-align: center; vertical-align: middle;\">\n <p>\u1798\u17B6\u1793 / Yes</p>\n </td>\n <td style=\"width:10%; text-align: center; vertical-align: middle;\">\n <p>\u1798\u17B7\u1793\u1798\u17B6\u1793 / No</p>\n </td>\n </tr>\n \n <% const additionalQuestions=health_info.additional_question_info; const questionNumbers=Array.from({ length: 17 },\n (_, i)=> i + 2); // q2 - q18\n %>\n \n <% questionNumbers.forEach(num=> { %>\n <tr class=\"question-row\">\n <td class=\"align-top space-y-2 text-justify\">\n <p>\n <%= num %>.\n <%= additionalQuestions['q' + num + '_question_kh'] %>\n </p>\n <p class=\"text-justify\">\n <%= additionalQuestions['q' + num + '_question_en'] %>\n </p>\n </td>\n \n <td style=\"text-align:center; vertical-align:middle;\">\n <%- renderCheck(additionalQuestions['q' + num], true) %>\n </td>\n \n <td style=\"text-align:center; vertical-align:middle;\">\n <%- renderCheck(additionalQuestions['q' + num], false) %>\n </td>\n <td class=\"text-justify align-top\">\n <div>\n <p>\n <%= additionalQuestions['q' + num + '_detail'] || '' %>\n </p>\n </div>\n </td>\n </tr>\n <% }) %>\n </table>\n \n <div class=\"question-row declaration-header\">\n <table class=\"table w-full table-fixed border-collapse form-table\" cellpadding=\"20\">\n <tr>\n <td colspan=\"4\" style=\"text-align:center;\" class=\"text-lg font-bold\">\n <h5>\u179F\u17C1\u1785\u1780\u17D2\u178F\u17B8\u1794\u17D2\u179A\u1780\u17B6\u179F\u179A\u1794\u179F\u17CB\u17A2\u17D2\u1793\u1780\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6</h5>\n <h5>DECLARATION BY THE APPLICANT</h5>\n </td>\n </tr>\n </table>\n \n <!-- Declaration by the application-->\n <div class=\"mt-5 space-y-3 text-justify\">\n <p>\u1781\u17D2\u179B\u17B9\u1798\u179F\u17B6\u179A\u1793\u17C3\u1796\u17B6\u1780\u17D2\u1799\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u1793\u17C1\u17C7\u178F\u17D2\u179A\u17BC\u179C\u1794\u17B6\u1793\u1796\u1793\u17D2\u1799\u179B\u17CB\u1799\u17C9\u17B6\u1784\u1785\u17D2\u1794\u17B6\u179F\u17CB\u17A0\u17BE\u1799\u1781\u17D2\u1789\u17BB\u17C6\u1794\u17B6\u1793\u1799\u179B\u17CB\u1791\u17B6\u17C6\u1784\u179F\u17D2\u179A\u17BB\u1784\u17D4\u200B</p>\n <p>The contents of this application have been explained to me, and I have fully understood them. </p>\n <p>\n \u1781\u17D2\u1789\u17BB\u17C6\u179F\u17BC\u1798\u1794\u1789\u17D2\u1787\u17B6\u1780\u17CB\u1790\u17B6\n \u1785\u1798\u17D2\u179B\u17BE\u1799\u178A\u17C2\u179B\u1795\u17D2\u178F\u179B\u17CB\u1787\u17BC\u1793\u1793\u17C5\u1780\u17D2\u1793\u17BB\u1784\u17AF\u1780\u179F\u17B6\u179A\u1793\u17C1\u17C7\u1796\u17B7\u178F\u1787\u17B6\u178F\u17D2\u179A\u17B9\u1798\u178F\u17D2\u179A\u17BC\u179C\u1791\u17C4\u17C7\u1794\u17B8\u1787\u17B6\u178F\u17D2\u179A\u17BC\u179C\u1794\u17B6\u1793\u1794\u17C6\u1796\u17C1\u1789\u178A\u17C4\u1799\u1781\u17D2\u1789\u17BB\u17C6\u17AC\u178A\u17C4\u1799\u17A2\u17D2\u1793\u1780\u1795\u17D2\u179F\u17C1\u1784\u1791\u17C0\u178F\u1780\u17D2\u1793\u17BB\u1784\u1793\u17B6\u1798\n \u179A\u1794\u179F\u17CB\u1781\u17D2\u1789\u17BB\u17C6\u1780\u17CF\u178A\u17C4\u1799\u1781\u17D2\u1789\u17BB\u17C6\u1791\u1791\u17BD\u179B\u1781\u17BB\u179F\u178F\u17D2\u179A\u17BC\u179C\u1791\u17B6\u17C6\u1784\u179F\u17D2\u179A\u17BB\u1784\u1785\u17C6\u1796\u17C4\u17C7\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u1791\u17B6\u17C6\u1784\u1793\u17C4\u17C7\u17A0\u17BE\u1799\u1781\u17D2\u1789\u17BB\u17C6\u1798\u17B7\u1793\u1794\u17B6\u1793\u179B\u17B6\u1780\u17CB\u1794\u17B6\u17C6\u1784\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u17A2\u17D2\u179C\u17B8\u1791\u17B6\u17C6\u1784\u17A2\u179F\u17CB\u17D4\n </p>\n <p>\n I confirm that the answers provided in this\n document are true, and whether written by me or anyone else on my behalf I\n accept full responsibility for them, and that I have not withheld any material\n information.\n </p>\n <p>\n \u1781\u17D2\u1789\u17BB\u17C6\u1799\u179B\u17CB\u179F\u17D2\u179A\u1794\u1790\u17B6\u1793\u17B9\u1784\u1798\u17B7\u1793\u1798\u17B6\u1793\u1780\u17B6\u179A\u1791\u1791\u17BD\u179B\u1781\u17BB\u179F\u178F\u17D2\u179A\u17BC\u179C\u178E\u17B6\u1798\u17BD\u1799\u1796\u17B8\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793\n <span class=\"font-bold text-lg\">\u17A0\u17D2\u179C\u17B8\u179B\u17B8\u1796 \u17A1\u17B6\u1799\u17A0\u17D2\u179C\u17CD \u17A2\u17B6\u179F\u17BD\u179A\u17C1\u1793 (\u1781\u17C1\u1798\u1794\u17BC\u178C\u17B6) \u1798.\u1780 </span>\n \u179A\u17A0\u17BC\u178F\u1791\u17B6\u179B\u17CB\u178F\u17C2\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\n \u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u1793\u17C1\u17C7\u178F\u17D2\u179A\u17BC\u179C\u1794\u17B6\u1793\u1785\u17C1\u1789\u1793\u17B7\u1784\u1794\u17D2\u179A\u1782\u179B\u17CB\u1787\u17BC\u1793\u1781\u17D2\u1789\u17BB\u17C6\u17A0\u17BE\u1799\u1794\u17BB\u1796\u17D2\u179C\u179B\u17B6\u1797\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u178A\u17C6\u1794\u17BC\u1784\u1794\u17B6\u1793\u1794\u1784\u17CB\u17D4\u179A\u17B6\u179B\u17CB\u1780\u17B6\u179A\u1791\u17BC\u1791\u17B6\u178F\u17CB\u1794\u17BB\u1796\u17D2\u179C\u179B\u17B6\u1797\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u1791\u17C5\u17B2\u17D2\u1799\u1798\u17D2\u1785\u17B6\u179F\u17CB\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\n \u17AC\u17A2\u17D2\u1793\u1780\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u1793\u17B9\u1784\u178F\u17D2\u179A\u17BC\u179C\u1792\u17D2\u179C\u17BE\u17A1\u17BE\u1784\u178F\u17B6\u1798\u179A\u1799\u17C8\u17AF\u1780\u179F\u17B6\u179A\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u1792\u1793\u17B6\u1782\u17B6\u179A\u178A\u17C2\u179B\u1794\u17B6\u1793\u1797\u17D2\u1787\u17B6\u1794\u17CB\u1780\u17D2\u1793\u17BB\u1784\u17A2\u17C6\u17A1\u17BB\u1784\u1796\u17C1\u179B\n \u178A\u17B6\u1780\u17CB\u1796\u17B6\u1780\u17D2\u1799\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u1793\u17C1\u17C7\u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17BE\u1782\u17D2\u1798\u17B6\u1793\u1780\u17B6\u179A\u1795\u17D2\u178A\u179B\u17CB\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u1792\u1793\u17B6\u1782\u17B6\u179A\u1790\u17D2\u1798\u17B8\u178E\u17B6\u1798\u17BD\u1799\u1798\u1780\u1780\u17B6\u1793\u17CB\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793\u17D4\n </p>\n </p>\n <p>I agree that there shall be no liability upon\n <span class=\"font-bold text-lg\">Phillip Life Assurance (Cambodia) Plc</span>. until a policy has\n been issued and\n delivered to me and the first premium is paid in full. All premium to be refunded to Policyholders\n or Applicants will\n be made through the bank information given\n during an application process, if no latest bank information has been provided and received by the\n company.\n </p>\n <p>\n \u1781\u17D2\u1789\u17BB\u17C6\u1799\u179B\u17CB\u1796\u17D2\u179A\u1798 \u1793\u17B7\u1784\u1795\u17D2\u178F\u179B\u17CB\u179F\u17B7\u1791\u17D2\u1792\u17B7\u17B2\u17D2\u1799\u179F\u17D2\u1790\u17B6\u1794\u17D0\u1793\u179C\u17C1\u1787\u17D2\u1787\u179F\u17B6\u179F\u17D2\u178F\u17D2\u179A\n \u1780\u17B6\u179A\u17B7\u1799\u17B6\u179B\u17D0\u1799\u179A\u1794\u179F\u17CB\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\n \u17AC\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u17A2\u17B6\u1799\u17BB\u1787\u17B8\u179C\u17B7\u178F\u178A\u1791\u17C3\u1791\u17C0\u178F \u178A\u17BE\u1798\u17D2\u1794\u17B8\u1794\u17D2\u179A\u1782\u179B\u17CB\u1791\u17C5\u17B2\u17D2\u1799\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\n <span class=\"font-bold text-lg\">\u17A0\u17D2\u179C\u17B8\u179B\u17B8\u1796 \u17A1\u17B6\u1799\u17A0\u17D2\u179C\u17CD \u17A2\u17B6\u179F\u17BD\u179A\u17C1\u1793 (\u1781\u17C1\u1798\u1794\u17BC\u178C\u17B6) \u1798.\u1780</span>\n \u1793\u17BC\u179C\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u1791\u17B6\u1780\u17CB\u1791\u1784\u1793\u17B9\u1784\u1781\u17D2\u1789\u17BB\u17C6\n \u1782\u17D2\u179A\u1794\u17CB\u1796\u17C1\u179B\u178A\u17C4\u1799\u1798\u17B7\u1793\u1782\u17B7\u178F\u1796\u17B8\u179B\u1791\u17D2\u1792\u1795\u179B\u1793\u17C3\u1796\u17B6\u1780\u17D2\u1799\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u179A\u1794\u179F\u17CB\u1781\u17D2\u1789\u17BB\u17C6\u17A1\u17BE\u1799\u17D4\n </p>\n <p>And I also agree and authorise (a) any\n medical source, insurance office, or other Life Insurance company to release to\n <span class=\"font-bold text-lg\">Phillip Life Assurance (Cambodia) Plc.</span> any relevant\n information concerning me\n at\n any time, regardless of the outcome of my application.\n </p>\n <p>\n \u1781\u17D2\u1789\u17BB\u17C6\u17A2\u1793\u17BB\u1789\u17D2\u1789\u17B6\u178F \u1793\u17B7\u1784\u1799\u179B\u17CB\u1796\u17D2\u179A\u1798\u17B2\u17D2\u1799\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793\u1794\u17D2\u179A\u17BE\u1794\u17D2\u179A\u17B6\u179F\u17CB\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u200B\n \u1793\u17B7\u1784\u1791\u17B7\u1793\u17D2\u1793\u1793\u17D0\u1799\u1791\u17B6\u17C6\u1784\u179F\u17D2\u179A\u17BB\u1784\u178A\u17C2\u179B\u1781\u17D2\u1789\u17BB\u17C6\u1794\u17B6\u1793\u1795\u17D2\u178A\u179B\u17CB\u1793\u17C5\u1780\u17D2\u1793\u17BB\u1784\u1796\u17B6\u1780\u17D2\u1799\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u179A\u1794\u179F\u17CB\u1781\u17D2\u1789\u17BB\u17C6\n \u1780\u17D2\u1793\u17BB\u1784\u1782\u17C4\u179B\u1794\u17C6\u178E\u1784\u179F\u17D2\u179A\u1794\u178F\u17B6\u1798\u1785\u17D2\u1794\u17B6\u1794\u17CB\u178A\u17BC\u1785\u1787\u17B6\u1780\u17B6\u179A\u1795\u17D2\u179F\u1796\u17D2\u179C\u1795\u17D2\u179F\u17B6\u1799\u1791\u17B8\u1795\u17D2\u179F\u17B6\u179A \u1780\u17B6\u179A\u179F\u17B7\u1780\u17D2\u179F\u17B6\u1791\u17B8\u1795\u17D2\u179F\u17B6\u179A \u1793\u17B7\u1784\u1780\u17B6\u179A\u1794\u1798\u17D2\u179A\u17BE\u17A2\u178F\u17B7\u1790\u17B7\u1787\u1793\u178A\u17C4\u1799\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793\n \u179F\u1798\u17D2\u1796\u17D0\u1793\u17D2\u1792\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793 \u17AC\u1787\u17B6\u178A\u17C3\u1782\u17BC\u1796\u17B6\u178E\u17B7\u1787\u17D2\u1787\u1780\u1798\u17D2\u1798\u179A\u1794\u179F\u17CB\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793\u178A\u17C4\u1799\u1798\u17B7\u1793\u1785\u17B6\u17C6\u1794\u17B6\u1785\u17CB\u1798\u17B6\u1793\u1780\u17B6\u179A\u1799\u179B\u17CB\u1796\u17D2\u179A\u1798\n \u1793\u17B7\u1784\u1787\u17BC\u1793\u178A\u17C6\u178E\u17B9\u1784\u1794\u1793\u17D2\u1790\u17C2\u1798\u1796\u17B8\u1781\u17D2\u1789\u17BB\u17C6\u17A1\u17BE\u1799\u17D4\n \u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793\u1798\u17B7\u1793\u178F\u17D2\u179A\u17BC\u179C\u1794\u17B6\u1793\u17A2\u1793\u17BB\u1789\u17D2\u1789\u17B6\u178F\u17B2\u17D2\u1799\u1794\u1789\u17D2\u1785\u17C1\u1789\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u178E\u17B6\u1798\u17BD\u1799\u1791\u17C5\u1797\u17B6\u1782\u17B8\u1791\u17B8\u1794\u17B8\u178E\u17B6\u1798\u17BD\u1799\u17AC\u1794\u17D2\u179A\u17BE\u1794\u17D2\u179A\u17B6\u179F\u17CB\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u1793\u17C4\u17C7\u179F\u1798\u17D2\u179A\u17B6\u1794\u17CB\u1782\u17C4\u179B\u1794\u17C6\u178E\u1784\u1795\u17D2\u179F\u17C1\u1784\u1791\u17C0\u178F\u178A\u17C2\u179B\u1798\u17B7\u1793\u1791\u17B6\u1780\u17CB\u1791\u1784\u1793\u17B9\u1784\u1782\u17C4\u179B\u1794\u17C6\u178E\u1784\u1791\u17B6\u17C6\u1784\u17A1\u17B6\u1799\u1781\u17B6\u1784\u179B\u17BE\u17A1\u17BE\u1799\n \u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17BE\u1782\u17D2\u1798\u17B6\u1793\u1780\u17B6\u179A\u1799\u179B\u17CB\u1796\u17D2\u179A\u1798\u1796\u17D2\u179A\u17C0\u1784\u1787\u17B6\u179B\u17B6\u1799\u179B\u1780\u17D2\u1781\u178E\u17CD\u17A2\u1780\u17D2\u179F\u179A\u1793\u17C4\u17C7\u17D4\n </p>\n <p style=\"margin-bottom:5px\">\n I authorize and consent the Company to use all of my information provided in my application form\n in legal purpose such as marketing, market survey and customer service by company, affiliate,\n or business partner without my prior consent or notification. The Company shall not allow to\n disclose any information of any other purpose not related to above mentioned purpose without prior\n consent in written.\n </p>\n </div>\n </div>\n \n <div class=\"question-row declaration-header\">\n <table class=\"width-100 form-table\" style=\"margin-top: 10px;\" cellpadding=\"15\">\n <tbody>\n <tr class=\"text-start-top\">\n <!-- Policyholder -->\n <td width=\"50%\">\n <div style=\"\n display: flex;\n flex-direction: column;\n justify-content: space-between;\n min-height: 250px;\n text-align: left; /* change to left */\n \">\n <div>\n <p style=\"margin:0;\">\n \u17A0\u178F\u17D2\u1790\u179B\u17C1\u1781\u17B6 \u17AC\u179F\u17D2\u1793\u17B6\u1798\u1798\u17C1\u178A\u17C3\u179A\u1794\u179F\u17CB\u1798\u17D2\u1785\u17B6\u179F\u17CB\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\n </p>\n <p style=\"margin:0;\">\n Signature or thumb print of Policyholder\n </p>\n </div>\n <div class=\"flex items-center gap-2 w-full\">\n <span>\u17A0\u178F\u17D2\u1790\u179B\u17C1\u1781\u17B6 \u17AC\u179F\u17D2\u1793\u17B6\u1798\u1798\u17C1\u178A\u17C3 / Signature or thumb print</span>\n \n <div class=\"flex-1 border-b border-black min-h-[18px] mt-1\"></div>\n </div>\n </div>\n </td>\n \n <!-- Life assured -->\n <td width=\"50%\">\n <div class=\"flex flex-col justify-between min-h-[250px] text-left\">\n <div>\n <p style=\"margin:0;\">\n \u17A0\u178F\u17D2\u1790\u179B\u17C1\u1781\u17B6 \u17AC\u179F\u17D2\u1793\u17B6\u1798\u1798\u17C1\u178A\u17C3\u179A\u1794\u179F\u17CB\u17A2\u17D2\u1793\u1780\u178F\u17D2\u179A\u17BC\u179C\u1794\u17B6\u1793\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\n (\u17A0\u178F\u17D2\u1790\u179B\u17C1\u1781\u17B6\u179A\u1794\u179F\u17CB\u17AA\u1796\u17BB\u1780\u1798\u17D2\u178F\u17B6\u1799 \u17AC\u17A2\u17B6\u178E\u17B6\u1796\u17D2\u1799\u17B6\u1794\u17B6\u179B\u179F\u17D2\u179A\u1794\u1785\u17D2\u1794\u17B6\u1794\u17CB \u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17BE\u17A2\u17D2\u1793\u1780\n \u178F\u17D2\u179A\u17BC\u179C\u1794\u17B6\u1793\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u1798\u17B6\u1793\u17A2\u17B6\u1799\u17BB\u1780\u17D2\u179A\u17C4\u1798 \u17E1\u17E8 \u1786\u17D2\u1793\u17B6\u17C6)\n </p>\n <p style=\"margin:0;\">\n Signature or thumb print of Life assured (Parent or the legal guardian's signature if the\n Life assured is less than 18\n years old)\n </p>\n </div>\n <div class=\"flex items-center gap-2 w-full\">\n <span>\u17A0\u178F\u17D2\u1790\u179B\u17C1\u1781\u17B6 \u17AC\u179F\u17D2\u1793\u17B6\u1798\u1798\u17C1\u178A\u17C3 / Signature or thumb print</span>\n \n <div class=\"flex-1 border-b border-black min-h-[18px] mt-1\"></div>\n </div>\n </div>\n </td>\n </tr>\n <!-- Names -->\n <tr>\n <td style=\"text-align: start; padding-top: 10px;\">\n <span>\u1788\u17D2\u1798\u17C4\u17C7</span>\n <span>/ Name:</span>\n <span style=\"font-weight: bold;\">\n <%= signature_info.ph_full_name %>\n </span>\n <!-- <span style=\"text-transform: uppercase; font-weight: bold;\">SOK CHANTHA</span> -->\n </td>\n <td style=\"text-align: start; padding-top: 10px;\">\n <span>\u1788\u17D2\u1798\u17C4\u17C7</span>\n <span>/ Name:</span>\n <span style=\"font-weight: bold;\">\n <%= signature_info.la_full_name %>\n </span>\n <!-- <span style=\"font-weight: bold;\">PHAN DARA</span> -->\n </td>\n </tr>\n <!-- Dates -->\n <tr>\n <td style=\"text-align: start; padding-top: 10px;\">\n <span>\u1780\u17B6\u179B\u1794\u179A\u17B7\u1785\u17D2\u1786\u17C1\u1791</span>\n <span>\n Date:\n <%- signature_info.ph_signature_date ? '<u><b>' + signature_info.ph_signature_date + '</b></u>'\n : '<span style=\"display:inline-block; width:120px; border-bottom:1px solid #000; min-height:18px;\"></span>'\n %>\n </span>\n </td>\n <td style=\"text-align: start; padding-top: 10px;\">\n <span>\u1780\u17B6\u179B\u1794\u179A\u17B7\u1785\u17D2\u1786\u17C1\u1791</span>\n <span>\n Date:\n <%- signature_info.la_signature_date ? '<u><b>' + signature_info.la_signature_date + '</b></u>'\n : '<span style=\"display:inline-block; width:120px; border-bottom:1px solid #000; min-height:18px;\"></span>'\n %>\n </span>\n </td>\n </tr>\n </tbody>\n </table>\n </div>\n \n <div class=\"question-row declaration-header\">\n <table class=\"form-table w-full table-fixed mt-2\" cellpadding=\"15\">\n <!-- Signature line -->\n <tr>\n <td style=\"height: 50px; vertical-align: center; text-align: start;\">\n <p>\n <span>\n \u17A0\u178F\u17D2\u1790\u179B\u17C1\u1781\u17B6 \u17AC\u179F\u17D2\u1793\u17B6\u1798\u1798\u17C1\u178A\u17C3\u179A\u1794\u179F\u17CB\u1791\u17B8\u1794\u17D2\u179A\u17B9\u1780\u17D2\u179F\u17B6\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784 \u17AC\u179F\u17B6\u1780\u17D2\u179F\u17B8\n </span>\n <span>\n (Signature or thumb print of Advisor/witness)\n </span>\n <br>\n <div class=\"flex-1 border-b border-black min-h-[50px] mt-1\"></div>\n </p>\n </td>\n </tr>\n <!-- Name -->\n <tr>\n <td style=\"text-align: start; vertical-align: center; padding-top: 5px;\">\n <span>\u1788\u17D2\u1798\u17C4\u17C7</span>\n <span>\n Name:\n <%- signature_info.agent_full_name ? '<u><b>' + signature_info.agent_full_name+ '</b></u>'\n : '<span style=\"display:inline-block; width:120px; border-bottom:1px solid #000; min-height:18px;\"></span>'\n %>\n </span>\n </td>\n </tr>\n <!-- Date -->\n <tr>\n <td style=\"text-align: start; vertical-align: center; padding-top: 5px;\">\n <span>\u1780\u17B6\u179B\u1794\u179A\u17B7\u1785\u17D2\u1786\u17C1\u1791</span>\n <span>\n Date:\n <%- signature_info.agent_signature_date ? '<u><b>' + signature_info.agent_signature_date+ '</b></u>'\n : '<span style=\"display:inline-block; width:120px; border-bottom:1px solid #000; min-height:18px;\"></span>'\n %>\n </span>\n </td>\n </tr>\n </table>\n </div>\n \n <div class=\"question-row declaration-header\">\n <table style=\"margin-top: 10px;\" class=\"width-100 form-table\" cellpadding=\"15\">\n <tbody class=\"width-100\">\n <!-- Title -->\n <tr class=\"width-100\" cellpadding=\"10\">\n <td colspan=\"3\" style=\"text-align:center;\" class=\"text-lg font-bold\">\n <h5>\u1780\u17B6\u179A\u1794\u1789\u17D2\u1787\u17B6\u1780\u17CB\u178A\u17C4\u1799\u17A2\u17D2\u1793\u1780\u178F\u17C6\u178E\u17B6\u1784 \u17A0\u17D2\u179C\u17B8\u179B\u17B8\u1796 \u17A1\u17B6\u1799\u17A0\u17D2\u179C\u17CD \u17A2\u17B6\u179F\u17BD\u179A\u17C1\u1793 (\u1781\u17C1\u1798\u1794\u17BC\u178C\u17B6) \u1798.\u1780</h5>\n <h5>Phillip Life Assurance (Cambodia) Plc Representative Certification</h5>\n </td>\n </tr>\n <!-- Content -->\n <tr>\n <td style=\"text-align: start;\">\n <p>\n \u1781\u17D2\u1789\u17BB\u17C6\u1794\u17B6\u1793\u1787\u17BD\u1794\u17A2\u17D2\u1793\u1780\u178A\u17B6\u1780\u17CB\u1796\u17B6\u1780\u17D2\u1799\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6 \u1793\u17B7\u1784\u17A2\u17D2\u1793\u1780\u178A\u17C2\u179B\u1793\u17B9\u1784\u178F\u17D2\u179A\u17BC\u179C\u1794\u17B6\u1793\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u178A\u17C4\u1799\u1795\u17D2\u1791\u17B6\u179B\u17CB\n \u1793\u17B7\u1784\u1794\u17B6\u1793\u1796\u1793\u17D2\u1799\u179B\u17CB\u17A2\u17C6\u1796\u17B8 \u1781 \u1793\u17B7\u1784\u179B\u1780\u17D2\u1781\u1781\u178E\u17D2\u178C\u1793\u17C3\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784\u178A\u179B\u17CB\u17A2\u17D2\u1793\u1780\u178A\u17B6\u1780\u17CB\u1796\u17B6\u1780\u17D2\u1799\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u17D4\n </p>\n \n <p>\n \u1781\u17D2\u1789\u17BB\u17C6\u1794\u17B6\u1793\u1783\u17BE\u1789\u17A2\u178F\u17D2\u178F\u179F\u1789\u17D2\u1789\u17B6\u178E\u1794\u17D0\u178E\u17D2\u178E\u179A\u1794\u179F\u17CB\u17A2\u17D2\u1793\u1780\u178A\u17B6\u1780\u17CB\u1796\u17B6\u1780\u17D2\u1799\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6 \u1793\u17B7\u1784\u1794\u17B6\u1793\u1790\u178F\u1785\u17C6\u179B\u1784\u178F\u17D2\u179A\u17B9\u1798\u178F\u17D2\u179A\u17BC\u179C\u178F\u17B6\u1798\u1785\u17D2\u1794\u17B6\u1794\u17CB\u178A\u17BE\u1798\u17D4\n \u1781\u17D2\u1789\u17BB\u17C6\u179F\u17BC\u1798\u1794\u1789\u17D2\u1787\u17B6\u1780\u17CB\u1790\u17B6\u179B\u17C1\u1781\u17A2\u178F\u17D2\u178F\u179F\u1789\u17D2\u1789\u17B6\u178E\u1794\u17D0\u178E\u17D2\u178E\u179A\u1794\u179F\u17CB\u17A2\u17D2\u1793\u1780\u178A\u17B6\u1780\u17CB\u1796\u17B6\u1780\u17D2\u1799\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u1782\u17BA\n <u><b>\n <%= rep_certification_info.identifier_no %>\n </b></u>\n \u1793\u17B7\u1784\u1798\u17B6\u1793\u1790\u17D2\u1784\u17C3\u1781\u17C2\u1786\u17D2\u1793\u17B6\u17C6\u1780\u17C6\u178E\u17BE\u178F\n <u><b>\n <%= rep_certification_info.date_of_birth %>\n </b></u>\n \u1796\u17B7\u178F\u1787\u17B6\u179A\u1794\u179F\u17CB\u17A2\u17D2\u1793\u1780\u178A\u17B6\u1780\u17CB\u1796\u17B6\u1780\u17D2\u1799\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u1796\u17B7\u178F\u1794\u17D2\u179A\u17B6\u1780\u178A\u1798\u17C2\u1793\u17D4\n </p>\n <br>\n <p class=\"text-justify\">\n I have personally seen the Applicant and the Life Assured and have explained the terms and\n conditions of the policy to\n the Applicant.\n I have seen the ID of the Applicant and original copy. I certify that the date of birth and ID\n number truly belong to\n the Applicant.\n </p>\n <br><br><br><br>\n \n <!-- Signature -->\n <p>\n <span>\u17A0\u178F\u17D2\u1790\u179B\u17C1\u1781\u17B6 \u1793\u17B7\u1784\u1788\u17D2\u1798\u17C4\u17C7</span>\n <span> / Signature and name: </span>\n <u>\n <span style=\"text-transform: uppercase; font-weight: bold\">\n <%= rep_certification_info.rep_full_name %>\n </span>\n </u>\n </p>\n </td>\n </tr>\n </tbody>\n </table>\n </div>\n \n <div class=\"question-row declaration-header\">\n <table style=\"margin-top: 10px; width: 100%; table-layout: fixed;\" class=\"form-table\" cellpadding=\"15\">\n <tbody>\n <!-- Header -->\n <tr>\n <td colspan=\"3\" style=\"text-align: center;\" class=\"text-lg font-bold\">\n <h5>\u17A0\u17D2\u179C\u17B8\u179B\u17B8\u1796 \u17A1\u17B6\u1799\u17A0\u17D2\u179C\u17CD \u17A2\u17B6\u179F\u17BD\u179A\u17C1\u1793 (\u1781\u17C1\u1798\u1794\u17BC\u178C\u17B6) \u1798.\u1780</h5>\n <h5>Phillip Life Assurance (Cambodia) Plc</h5>\n </td>\n </tr>\n <!-- Content -->\n <tr>\n <td style=\"text-align: left;\" colspan=\"3\">\n <div>\n <span>\u179F\u1798\u17D2\u179A\u17B6\u1794\u17CB\u1794\u17D2\u179A\u17BE\u1780\u17D2\u1793\u17BB\u1784\u1780\u17D2\u179A\u17BB\u1798\u17A0\u17CA\u17BB\u1793\u178F\u17C2\u1794\u17C9\u17BB\u178E\u17D2\u178E\u17C4\u17C7</span>\n <span>/ For office Use Only:</span>\n \n <p style=\"text-align: left;\">\n <span>\u179B\u17C1\u1781\u1796\u17B6\u1780\u17D2\u1799\u179F\u17D2\u1793\u17BE\u179F\u17BB\u17C6\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784</span>\n <span>/ Application Number:</span>\n <span style=\"font-weight: bold\">\n <%= agent_source_info.application_no %>\n </span>\n </p>\n <p style=\"text-align: left;\">\n <span>\u179B\u17C1\u1781\u179F\u1798\u17D2\u1782\u17B6\u179B\u17CB\u17A2\u178F\u17B7\u1790\u17B7\u1787\u1793</span>\n <span>/ Client Number:</span>\n <span style=\"font-weight: bold\">\n <%= agent_source_info.client_no %>\n </span>\n </p>\n <p style=\"text-align: left;\">\n <span>\u179B\u17C1\u1781\u1794\u178E\u17D2\u178E\u179F\u1793\u17D2\u1799\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784</span>\n <span>/ Policy Number:</span>\n <span style=\"font-weight: bold\">\n <%= agent_source_info.policy_no %>\n </span>\n </p>\n <p style=\"text-align: left;\">\n <span>\u179B\u17C1\u1781\u179F\u1798\u17D2\u1782\u17B6\u179B\u17CB\u1794\u17D2\u179A\u1797\u1796</span>\n <span>/ Source Code:</span>\n <span style=\"font-weight: bold\">\n <%= agent_source_info.source_code %>\n </span>\n </p>\n <p style=\"text-align: left;\">\n <span>\u179B\u17C1\u1781\u179F\u1798\u17D2\u1782\u17B6\u179B\u17CB\u17A2\u17D2\u1793\u1780\u1794\u17D2\u179A\u17B9\u1780\u17D2\u179F\u17B6\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784</span>\n <span>/ Insurance Advisor Code:</span>\n <span style=\"font-weight: bold\">\n <%= agent_source_info.advisor_code %>\n </span>\n </p>\n <p style=\"text-align: left;\">\n <span>\u179B\u17C1\u1781\u1791\u17BC\u179A\u179F\u17D0\u1796\u17D2\u1791\u17A2\u17D2\u1793\u1780\u1794\u17D2\u179A\u17B9\u1780\u17D2\u179F\u17B6\u1792\u17B6\u1793\u17B6\u179A\u17C9\u17B6\u1794\u17CB\u179A\u1784</span>\n <span>/ Insurance Advisor Contact Number:</span>\n <span style=\"font-weight: bold\">\n <%= agent_source_info.advisor_contact %>\n </span>\n </p>\n </div>\n </td>\n </tr>\n \n </tbody>\n </table>\n <div class=\"mt-5 space-y-2\">\n <p>\u1796\u17D0\u178F\u17CC\u1798\u17B6\u1793\u179B\u1798\u17D2\u17A2\u17B7\u178F\u1794\u1793\u17D2\u1790\u17C2\u1798:\n \u179F\u17BC\u1798\u1794\u17D2\u179A\u17BE\u1794\u17D2\u179A\u17B6\u179F\u17CB\u1780\u1793\u17D2\u179B\u17C2\u1784\u1781\u17B6\u1784\u1780\u17D2\u179A\u17C4\u1798\u178A\u17BE\u1798\u17D2\u1794\u17B8\u1786\u17D2\u179B\u17BE\u1799\u1793\u17B9\u1784\u179F\u17C6\u178E\u17BD\u179A\u1794\u17D2\u179A\u179F\u17B7\u1793\u1794\u17BE\u1791\u17C6\u17A0\u17C6\u1793\u17C5\u1780\u17D2\u1793\u17BB\u1784\u1780\u1798\u17D2\u179A\u1784\u179F\u17C6\u178E\u17BD\u179A\u1781\u17B6\u1784\u179B\u17BE\u1798\u17B7\u1793\u1782\u17D2\u179A\u1794\u17CB\u1782\u17D2\u179A\u17B6\u1793\u17CB\u17D4</p>\n <p>Additional Details: Please use the space bellow if there are insufficient space in the\n questionnaire to provide your answers.</p>\n </div>\n </div>\n \n \n </div>\n </div>\n </div>\n </body>\n\n</html>\n";
package/dist/libs/pdf-form/templates/uw-form.template.js CHANGED
@@ -63,7 +63,7 @@ exports.UW_FORM_TEMPLATE = `
63
63
  @media print {
64
64
  @page {
65
65
  size: A3 portrait;
66
- margin: 10mm 10mm 0mm 10mm;
66
+ margin: 10mm 10mm 20mm 10mm;
67
67
  }
68
68
  }
69
69
 
package/dist/types/pdf-form/sio-form.type.d.ts CHANGED
@@ -67,6 +67,11 @@ export interface ISIOSignatureInfo {
67
67
  witness_name: string;
68
68
  witness_signature_date: string;
69
69
  }
70
+ export interface ISIOLoanInfo {
71
+ loan_amount: string;
72
+ loan_duration: string;
73
+ loan_type: string;
74
+ }
70
75
  export interface ISIOFormData {
71
76
  logo?: string;
72
77
  branch_staff_app_info: ISIOBranchStaffAppInfo;
@@ -76,4 +81,5 @@ export interface ISIOFormData {
76
81
  beneficiary_info: ISIOBeneficiaryInfo[];
77
82
  health_info: ISIOHealthInfo;
78
83
  signature_info: ISIOSignatureInfo;
84
+ loan_info: ISIOLoanInfo;
79
85
  }
package/package.json CHANGED
@@ -1,6 +1,6 @@
1
1
  {
2
2
  "name": "plac-micro-common",
3
- "version": "1.3.93",
3
+ "version": "1.3.95",
4
4
  "types": "dist/index.d.ts",
5
5
  "main": "dist/index.js",
6
6
  "scripts": {