plac-micro-common 1.3.95 → 1.3.96

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Files changed (7) hide show
  1. package/dist/libs/pdf-form/templates/receipt.template.d.ts +1 -1
  2. package/dist/libs/pdf-form/templates/receipt.template.js +224 -210
  3. package/dist/libs/pdf-form/templates/sio-form-kh.template.d.ts +1 -1
  4. package/dist/libs/pdf-form/templates/sio-form-kh.template.js +845 -657
  5. package/dist/libs/pdf-form/templates/uw-form.template.d.ts +1 -1
  6. package/dist/libs/pdf-form/templates/uw-form.template.js +1551 -1533
  7. package/package.json +1 -1
package/dist/libs/pdf-form/templates/uw-form.template.js CHANGED
@@ -63,10 +63,21 @@ exports.UW_FORM_TEMPLATE = `
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  @media print {
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  @page {
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  size: A3 portrait;
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- margin: 10mm 10mm 20mm 10mm;
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+ margin: 8mm 8mm 20mm 8mm;
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  }
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  }
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+ .check-mark {
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+ display: inline-block;
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+ width: 8px;
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+ height: 15px;
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+ border: solid #000;
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+ border-width: 0 2px 2px 0;
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+ transform: rotate(45deg);
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+ margin-bottom: 2px;
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+ vertical-align: middle;
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+ }
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+
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  .page {
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  width: 297mm;
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  /* A3 portrait width */
@@ -96,8 +107,7 @@ exports.UW_FORM_TEMPLATE = `
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  <% 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>';
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  } %>
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- <% function renderCheck(value, expected) { return value===expected
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- ? '<span style="font-size:16px; font-weight:bold;">&#10003;</span>' : '' ; } %>
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+ <% function renderCheck(value, expected) { return value===expected ? '<span class="check-mark"></span>' : '' ; } %>
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102
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  <body>
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  <script>
@@ -156,7 +166,7 @@ exports.UW_FORM_TEMPLATE = `
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  }
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  }
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  </script>
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-
169
+
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  <div id="pages-wrapper">
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  <div class="page">
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  <div id="first-off-page">
@@ -170,7 +180,7 @@ exports.UW_FORM_TEMPLATE = `
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  <th style="background:#ebebeb; border:1px solid;">
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  <img src="data:image/png;base64,<%= logo_base64 %>" alt="Logo" class="title-logo" width="200px" />
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182
  </th>
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-
183
+
174
184
  <th style="background:#dddddd; border:1px solid;" class="space-y-2">
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  <p class="font-moul text-2xl">
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186
  ពាក្យសេី្នសុំធានារ៉ាប់រងអាយុជីវិត
@@ -181,7 +191,7 @@ exports.UW_FORM_TEMPLATE = `
181
191
  </th>
182
192
  </tr>
183
193
  </table>
184
-
194
+
185
195
  <div class="space-y-2 text-align">
186
196
  <p>សូមផ្តល់ព័ត៌មានមកក្រុមហ៊ុនឱ្យបានគ្រប់គ្រាន់ និងត្រឹមត្រូវ។ ការផ្តល់ព័ត៌មានមិនត្រឹមត្រូវ ឬក្លែងបន្លំ
187
197
  នាំឱ្យបណ្ណសន្យារ៉ាប់រងមោឃភាព ឬត្រូវលុបចោល។</p>
@@ -189,317 +199,318 @@ exports.UW_FORM_TEMPLATE = `
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  result
190
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  in
191
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  the policy issued being cancelled or voided.</p>
192
- </div>
193
-
194
- <table class="table w-full table-fixed border-collapse form-table" cellpadding="10">
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- <colgroup>
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- <col style="width: 17%">
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- <col style="width: 17%">
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- <col style="width: 8%">
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- <col style="width: 8%">
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- <col style="width: 17%">
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- <col style="width: 17%">
202
- <col style="width: 8%">
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- <col style="width: 8%">
204
- </colgroup>
205
- <thead>
206
- <tr>
207
- <th colspan="4" class="w-1/2 border border-black">
208
- <p>ផ្នែកទី១: ​ព័ត៌មានអំពីម្ចាស់បណ្ណសន្យារ៉ាប់រង</p>
209
- <p>Part 1: INFORMATION ABOUT THE POLICYHOLDER</p>
210
- </th>
211
-
212
- <th colspan="4" class="w-1/2 border border-black">
213
- <p>ផ្នែកទី១: ព័ត៌មានអំពីអ្នកត្រូវបានធានារ៉ាប់រង</p>
214
- <p>( ប្រសិនបេីខុសពីម្ចាស់បណ្ណសន្យារ៉ាប់រង )</p>
215
- <p>Part 1: INFORMATION ABOUT THE LIFE ASSURED</p>
216
- <p>( if different from the policyholder )</p>
217
- </th>
218
- </tr>
219
-
220
- <!-- Full Name Value -->
221
- <tr>
222
- <td colspan="4">
223
- <p>ឈ្មេាះពេញដូចបង្ហាញនៅក្នុងអត្តសញ្ញាណបណ្ណ / លិខិតឆ្លងដែន / សំបុត្រកំណេីត / ប័ណ្ណប៉ាតង់
224
- (ជាភាសាខ្មែរ និងអង់គ្លេស)</p>
202
+ </div>
203
+
204
+ <table class="table w-full table-fixed border-collapse form-table" cellpadding="10">
205
+ <colgroup>
206
+ <col style="width: 17%">
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+ <col style="width: 17%">
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+ <col style="width: 8%">
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+ <col style="width: 8%">
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+ <col style="width: 17%">
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+ <col style="width: 17%">
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+ <col style="width: 8%">
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+ <col style="width: 8%">
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+ </colgroup>
215
+ <thead>
216
+ <tr>
217
+ <th colspan="4" class="w-1/2 border border-black">
218
+ <p>ផ្នែកទី១: ​ព័ត៌មានអំពីម្ចាស់បណ្ណសន្យារ៉ាប់រង</p>
219
+ <p>Part 1: INFORMATION ABOUT THE POLICYHOLDER</p>
220
+ </th>
221
+
222
+ <th colspan="4" class="w-1/2 border border-black">
223
+ <p>ផ្នែកទី១: ព័ត៌មានអំពីអ្នកត្រូវបានធានារ៉ាប់រង</p>
224
+ <p>( ប្រសិនបេីខុសពីម្ចាស់បណ្ណសន្យារ៉ាប់រង )</p>
225
+ <p>Part 1: INFORMATION ABOUT THE LIFE ASSURED</p>
226
+ <p>( if different from the policyholder )</p>
227
+ </th>
228
+ </tr>
229
+
230
+ <!-- Full Name Value -->
231
+ <tr>
232
+ <td colspan="4">
233
+ <p>ឈ្មេាះពេញដូចបង្ហាញនៅក្នុងអត្តសញ្ញាណបណ្ណ / លិខិតឆ្លងដែន / សំបុត្រកំណេីត / ប័ណ្ណប៉ាតង់
234
+ (ជាភាសាខ្មែរ និងអង់គ្លេស)</p>
225
235
  <p class=" ">Full name as shown in ID card / Passport / Birth Certificate / Patent Tax (Khmer
226
236
  and
227
237
  English)</p>
228
- </td>
229
- <td colspan="4">
230
- <p>ឈ្មេាះពេញដូចបង្ហាញនៅក្នុងអត្តសញ្ញាណបណ្ណ / លិខិតឆ្លងដែន / សំបុត្រកំណេីត (ជាភាសាខ្មែរ
231
- និងអង់គ្លេស)</p>
238
+ </td>
239
+ <td colspan="4">
240
+ <p>ឈ្មេាះពេញដូចបង្ហាញនៅក្នុងអត្តសញ្ញាណបណ្ណ / លិខិតឆ្លងដែន / សំបុត្រកំណេីត (ជាភាសាខ្មែរ
241
+ និងអង់គ្លេស)</p>
232
242
  <p class=" ">Full name as shown in ID card / Passport / Birth Certificate (Khmer and English)
233
243
  </p>
234
- </td>
235
- </tr>
236
- <tr>
237
- <td colspan="4">
238
- <span class="font-bold text-md">
239
- <%= ph.full_name %>
244
+ </td>
245
+ </tr>
246
+ <tr>
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+ <td colspan="4">
248
+ <span class="font-bold text-md">
249
+ <%= ph.full_name %>
250
+ </span>
251
+ </td>
252
+ <td colspan="4">
253
+ <span class="font-bold text-md">
254
+ <%= la.full_name %>
255
+ </span>
256
+ </td>
257
+ </tr>
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+
259
+ <!-- Present Address Label -->
260
+ <tr>
261
+ <td colspan="4">
262
+ <span class="">អាសយដ្ឋានបច្ចុប្បន្ន /</span>
263
+ <span class=" ">Present Address</span>
264
+ </td>
265
+ <td colspan="4">
266
+ <span class="">អាសយដ្ឋានបច្ចុប្បន្ន /</span>
267
+ <span class=" ">Present Address</span>
268
+ </td>
269
+ </tr>
270
+ <tr>
271
+ <td colspan="4">
272
+ <span class="font-bold">
273
+ <%= ph.present_address %>
274
+ </span>
275
+ </td>
276
+ <td colspan="4">
277
+ <span class="font-bold">
278
+ <%= la.present_address %>
279
+ </span>
280
+ </td>
281
+ </tr>
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+
283
+ <!-- Phone / Relationship Label -->
284
+ <tr>
285
+ <td colspan="4">
286
+ <ol class="list-decimal pl-5">
287
+ <li>
288
+ <span>លេខទូរស័ព្ទផ្ទាល់ខ្លួន / អុីម៉ែល /</span>
289
+ <span>Phone Number / Email</span>
290
+ </li>
291
+ <li>
292
+ <span>ទំនាក់ទំនងជាមួយអ្នកត្រូវបានធានារ៉ាប់រង /</span>
293
+ <span>Relationship to Life Assured</span>
294
+ </li>
295
+ </ol>
296
+ </td>
297
+
298
+ <td colspan="4">
299
+ <ol class="list-decimal pl-5">
300
+ <li>
301
+ <span>លេខទូរស័ព្ទផ្ទាល់ខ្លួន / អុីម៉ែល /</span>
302
+ <span>Phone Number / Email</span>
303
+ </li>
304
+ <li>
305
+ <span>ទំនាក់ទំនងជាមួយម្ចាស់បណ្ណសន្យារ៉ាប់រង /</span>
306
+ <span>Relationship to Policyholder</span>
307
+ </li>
308
+ </ol>
309
+ </td>
310
+ </tr>
311
+
312
+ <tr class="font-bold">
313
+ <td colspan="4">
314
+ <ol class="list-decimal pl-5">
315
+ <li>
316
+ <span>Primary Contact: <%= ph.contact_info %> </span>
317
+ </li>
318
+ <li>
319
+ <span>
320
+ <%= ph.ph_la_relationship %>
240
321
  </span>
241
- </td>
242
- <td colspan="4">
243
- <span class="font-bold text-md">
244
- <%= la.full_name %>
322
+ </li>
323
+ </ol>
324
+ </td>
325
+
326
+ <td colspan="4">
327
+ <ol class="list-decimal pl-5">
328
+ <li>
329
+ <span>Primary Contact: <%= la.contact_info %> </span>
330
+ </li>
331
+ <li>
332
+ <span>
333
+ <%= la.ph_la_relationship %>
245
334
  </span>
246
- </td>
335
+ </li>
336
+ </ol>
337
+ </td>
338
+ </tr>
339
+
340
+ <!-- PH = LA / PH ≠ LA -->
341
+ <tr>
342
+ <td colspan="4">
343
+ <div class="flex items-center gap-2">
344
+ <input type="checkbox" <%=isphla_same_person ? 'checked' : '' %> />
345
+ <span>ម្ចាស់បណ្ណសន្យារ៉ាប់រង = អ្នកត្រូវបានធានារ៉ាប់រង</span>
346
+ <span>/</span>
347
+ <span>PH = LA</span>
348
+ </div>
349
+ </td>
350
+ <td colspan="4">
351
+ <div class="flex items-center gap-2">
352
+ <input type="checkbox" <%=!isphla_same_person ? 'checked' : '' %> />
353
+ <span>ម្ចាស់បណ្ណសន្យារ៉ាប់រង </span> &ne; <span>អ្នកត្រូវបានធានារ៉ាប់រង</span>
354
+ <span>/</span>
355
+ <span>PH ≠ LA</span>
356
+ </div>
357
+ </td>
358
+ </tr>
359
+
360
+ <!-- Nationality / ID / Gender / Age Labels -->
361
+ <% const headers=[ { kh: "សញ្ជាតិ" , en: "Nationality" }, { kh: "លេខអត្តសញ្ញាណប័ណ្ណ/លិខិតឆ្លងដែន" ,
362
+ en: "ID / Passport Number" }, { kh: "ភេទ" , en: "Gender" }, { kh: "អាយុ" , en: "Age" } ]; %>
363
+
364
+ <tr>
365
+ <% for (let i=0; i < 2; i++) { %>
366
+ <% headers.forEach((h, idx)=> { %>
367
+
368
+ <td class="align-top <%= idx === headers.length - 1 ? 'text-center' : 'text-start' %>">
369
+ <div class="flex flex-col justify-center h-full">
370
+ <p class="text-sm">
371
+ <%= h.kh %>
372
+ </p>
373
+ <p class="text-sm">
374
+ <%= h.en %>
375
+ </p>
376
+ </div>
377
+ </td>
378
+
379
+ <% }) %>
380
+ <% } %>
381
+ </tr>
382
+
383
+ <!-- Nationality / ID / Gender / Age Values -->
384
+ <tr>
385
+ <td class="text-start-top">
386
+ <p class="font-bold">
387
+ <%= ph.nationality %>
388
+ </p>
389
+ </td>
390
+ <td class="text-start-top">
391
+ <p class="font-bold">
392
+ <%= ph.identifier_no %>
393
+ </p>
394
+ </td>
395
+ <td class="text-start-top">
396
+ <p class="font-bold">
397
+ <%= ph.gender %>
398
+ </p>
399
+ </td>
400
+ <td class="text-start-top text-center">
401
+ <span class="font-bold">
402
+ <%= ph.age %>
403
+ </span>
404
+ </td>
405
+
406
+ <td class="text-start-top">
407
+ <p class="font-bold">
408
+ <%= la.nationality %>
409
+ </p>
410
+ </td>
411
+ <td class="text-start-top">
412
+ <p class=" font-bold">
413
+ <%= la.identifier_no %>
414
+ </p>
415
+ </td>
416
+ <td class="text-start-top">
417
+ <p class="font-bold">
418
+ <%= la.gender %>
419
+ </p>
420
+ </td>
421
+ <td class="text-start-top text-center">
422
+ <span class="font-bold ">
423
+ <%= la.age %>
424
+ </span>
425
+ </td>
426
+ </tr>
427
+
428
+ <!-- DOB / Marital / Children Labels -->
429
+ <% const fields=[ { kh: "ថ្ងៃខែឆ្នាំ និងទីកន្លែងកំណើត" , en: "Date and Place of Birth" , colspan:
430
+ 1 }, { kh: "នៅលីវ / រៀបការរួច / លែងលះ / ពោះម៉ាយ ឬមេម៉ាយ" ,
431
+ en: "Single / Married / Divorced / Widowed" , colspan: 1 }, { kh: "ចំនួនកូន" ,
432
+ en: "Number of Children" , colspan: 2 } ]; %>
433
+
434
+ <tr>
435
+ <% for (let i=0; i < 2; i++) { %>
436
+ <% fields.forEach(field=> { %>
437
+
438
+ <td colspan="<%= field.colspan %>" class="text-start-top align-top">
439
+ <p class="text-sm">
440
+ <%= field.kh %>
441
+ </p>
442
+ <p class="text-sm">
443
+ <%= field.en %>
444
+ </p>
445
+ </td>
446
+
447
+ <% }) %>
448
+ <% } %>
247
449
  </tr>
248
-
249
- <!-- Present Address Label -->
450
+
250
451
  <tr>
251
- <td colspan="4">
252
- <span class="">អាសយដ្ឋានបច្ចុប្បន្ន /</span>
253
- <span class=" ">Present Address</span>
452
+ <td class="text-start-top" style="line-height:1.7">
453
+ <p class="font-bold text-sm">
454
+ <%= ph.dob_and_pob || '' %>
455
+ </p>
254
456
  </td>
255
- <td colspan="4">
256
- <span class="">អាសយដ្ឋានបច្ចុប្បន្ន /</span>
257
- <span class=" ">Present Address</span>
457
+ <td class="text-start-top text-center">
458
+ <p class="font-bold">
459
+ <%= ph.martial_status %>
460
+ </p>
258
461
  </td>
259
- </tr>
260
- <tr>
261
- <td colspan="4">
262
- <span class="font-bold">
263
- <%= ph.present_address %>
264
- </span>
462
+ <td colspan="2" class="text-start-top text-center">
463
+ <p class=" font-bold">
464
+ <%= ph.number_of_children %>
465
+ </p>
265
466
  </td>
266
- <td colspan="4">
267
- <span class="font-bold">
268
- <%= la.present_address %>
269
- </span>
467
+
468
+ <td class="text-start-top" style="line-height:1.7">
469
+ <p class="font-bold text-sm">
470
+ <%= la.dob_and_pob || '' %>
471
+ </p>
270
472
  </td>
271
- </tr>
272
-
273
- <!-- Phone / Relationship Label -->
274
- <tr>
275
- <td colspan="4">
276
- <ol class="list-decimal pl-5">
277
- <li>
278
- <span>លេខទូរស័ព្ទផ្ទាល់ខ្លួន / អុីម៉ែល /</span>
279
- <span>Phone Number / Email</span>
280
- </li>
281
- <li>
282
- <span>ទំនាក់ទំនងជាមួយអ្នកត្រូវបានធានារ៉ាប់រង /</span>
283
- <span>Relationship to Life Assured</span>
284
- </li>
285
- </ol>
473
+ <td class="text-start-top text-center">
474
+ <p class=" font-bold">
475
+ <%= la.martial_status %>
476
+ </p>
286
477
  </td>
287
-
288
- <td colspan="4">
289
- <ol class="list-decimal pl-5">
290
- <li>
291
- <span>លេខទូរស័ព្ទផ្ទាល់ខ្លួន / អុីម៉ែល /</span>
292
- <span>Phone Number / Email</span>
293
- </li>
294
- <li>
295
- <span>ទំនាក់ទំនងជាមួយម្ចាស់បណ្ណសន្យារ៉ាប់រង /</span>
296
- <span>Relationship to Policyholder</span>
297
- </li>
298
- </ol>
478
+ <td colspan="2" class="text-start-top text-center">
479
+ <p class=" font-bold">
480
+ <%= la.number_of_children %>
481
+ </p>
299
482
  </td>
300
483
  </tr>
301
-
302
- <tr class="font-bold">
484
+
485
+ <!-- Employer Name Label -->
486
+ <tr>
303
487
  <td colspan="4">
304
- <ol class="list-decimal pl-5">
305
- <li>
306
- <span>Primary Contact: <%= ph.contact_info %> </span>
307
- </li>
308
- <li>
309
- <span>
310
- <%= ph.ph_la_relationship %>
311
- </span>
312
- </li>
313
- </ol>
488
+ <span>ឈ្មោះ និងអាសយដ្ឋានរបស់និយោជក /</span>
489
+ <span>Name and Address of Employer</span>
314
490
  </td>
315
-
316
491
  <td colspan="4">
317
- <ol class="list-decimal pl-5">
318
- <li>
319
- <span>Primary Contact: <%= la.contact_info %> </span>
320
- </li>
321
- <li>
322
- <span>
323
- <%= la.ph_la_relationship %>
324
- </span>
325
- </li>
326
- </ol>
492
+ <span>ឈ្មោះ និងអាសយដ្ឋានរបស់និយោជក /</span>
493
+ <span>Name and Address of Employer</span>
327
494
  </td>
328
495
  </tr>
329
-
330
- <!-- PH = LA / PH ≠ LA -->
496
+
497
+ <!-- Employer Name Value -->
331
498
  <tr>
332
499
  <td colspan="4">
333
- <div class="flex items-center gap-2">
334
- <input type="checkbox" <%=isphla_same_person ? 'checked' : '' %> />
335
- <span>ម្ចាស់បណ្ណសន្យារ៉ាប់រង = អ្នកត្រូវបានធានារ៉ាប់រង</span>
336
- <span>/</span>
337
- <span>PH = LA</span>
338
- </div>
500
+ <span class="font-khmer font-bold">
501
+ <%= ph.name_and_address_of_employer || 'N/A' %>
502
+ </span>
339
503
  </td>
340
504
  <td colspan="4">
341
- <div class="flex items-center gap-2">
342
- <input type="checkbox" <%=!isphla_same_person ? 'checked' : '' %> />
343
- <span>ម្ចាស់បណ្ណសន្យារ៉ាប់រង </span> &ne; <span>អ្នកត្រូវបានធានារ៉ាប់រង</span>
344
- <span>/</span>
345
- <span>PH ≠ LA</span>
346
- </div>
505
+ <span class="font-khmer font-bold">
506
+ <%= la.name_and_address_of_employer || 'N/A' %>
507
+ </span>
347
508
  </td>
348
509
  </tr>
349
-
350
- <!-- Nationality / ID / Gender / Age Labels -->
351
- <% const headers=[ { kh: "សញ្ជាតិ" , en: "Nationality" }, { kh: "លេខអត្តសញ្ញាណប័ណ្ណ/លិខិតឆ្លងដែន" ,
352
- en: "ID / Passport Number" }, { kh: "ភេទ" , en: "Gender" }, { kh: "អាយុ" , en: "Age" } ]; %>
353
-
354
- <tr>
355
- <% for (let i=0; i < 2; i++) { %>
356
- <% headers.forEach((h, idx)=> { %>
357
-
358
- <td class="align-top <%= idx === headers.length - 1 ? 'text-center' : 'text-start' %>">
359
- <div class="flex flex-col justify-center h-full">
360
- <p class="text-sm">
361
- <%= h.kh %>
362
- </p>
363
- <p class="text-sm">
364
- <%= h.en %>
365
- </p>
366
- </div>
367
- </td>
368
-
369
- <% }) %>
370
- <% } %>
371
- </tr>
372
-
373
- <!-- Nationality / ID / Gender / Age Values -->
374
- <tr>
375
- <td class="text-start-top">
376
- <p class="font-bold">
377
- <%= ph.nationality %>
378
- </p>
379
- </td>
380
- <td class="text-start-top">
381
- <p class="font-bold">
382
- <%= ph.identifier_no %>
383
- </p>
384
- </td>
385
- <td class="text-start-top">
386
- <p class="font-bold">
387
- <%= ph.gender %>
388
- </p>
389
- </td>
390
- <td class="text-start-top text-center">
391
- <span class="font-bold">
392
- <%= ph.age %>
393
- </span>
394
- </td>
395
-
396
- <td class="text-start-top">
397
- <p class="font-bold">
398
- <%= la.nationality %>
399
- </p>
400
- </td>
401
- <td class="text-start-top">
402
- <p class=" font-bold">
403
- <%= la.identifier_no %>
404
- </p>
405
- </td>
406
- <td class="text-start-top">
407
- <p class="font-bold">
408
- <%= la.gender %>
409
- </p>
410
- </td>
411
- <td class="text-start-top text-center">
412
- <span class="font-bold ">
413
- <%= la.age %>
414
- </span>
415
- </td>
416
- </tr>
417
-
418
- <!-- DOB / Marital / Children Labels -->
419
- <% const fields=[ { kh: "ថ្ងៃខែឆ្នាំ និងទីកន្លែងកំណើត" , en: "Date and Place of Birth" , colspan: 1 }, {
420
- kh: "នៅលីវ / រៀបការរួច / លែងលះ / ពោះម៉ាយ ឬមេម៉ាយ" , en: "Single / Married / Divorced / Widowed" , colspan: 1 }, {
421
- kh: "ចំនួនកូន" , en: "Number of Children" , colspan: 2 } ]; %>
422
-
423
- <tr>
424
- <% for (let i=0; i < 2; i++) { %>
425
- <% fields.forEach(field=> { %>
426
510
 
427
- <td colspan="<%= field.colspan %>" class="text-start-top align-top">
428
- <p class="text-sm">
429
- <%= field.kh %>
430
- </p>
431
- <p class="text-sm">
432
- <%= field.en %>
433
- </p>
434
- </td>
435
-
436
- <% }) %>
437
- <% } %>
438
- </tr>
439
-
440
- <tr>
441
- <td class="text-start-top" style="line-height:1.7">
442
- <p class="font-bold text-sm">
443
- <%= ph.dob_and_pob || '' %>
444
- </p>
445
- </td>
446
- <td class="text-start-top text-center">
447
- <p class="font-bold">
448
- <%= ph.martial_status %>
449
- </p>
450
- </td>
451
- <td colspan="2" class="text-start-top text-center">
452
- <p class=" font-bold">
453
- <%= ph.number_of_children %>
454
- </p>
455
- </td>
456
-
457
- <td class="text-start-top" style="line-height:1.7">
458
- <p class="font-bold text-sm">
459
- <%= la.dob_and_pob || '' %>
460
- </p>
461
- </td>
462
- <td class="text-start-top text-center">
463
- <p class=" font-bold">
464
- <%= la.martial_status %>
465
- </p>
466
- </td>
467
- <td colspan="2" class="text-start-top text-center">
468
- <p class=" font-bold">
469
- <%= la.number_of_children %>
470
- </p>
471
- </td>
472
- </tr>
473
-
474
- <!-- Employer Name Label -->
475
- <tr>
476
- <td colspan="4">
477
- <span>ឈ្មោះ និងអាសយដ្ឋានរបស់និយោជក /</span>
478
- <span>Name and Address of Employer</span>
479
- </td>
480
- <td colspan="4">
481
- <span>ឈ្មោះ និងអាសយដ្ឋានរបស់និយោជក /</span>
482
- <span>Name and Address of Employer</span>
483
- </td>
484
- </tr>
485
-
486
- <!-- Employer Name Value -->
487
- <tr>
488
- <td colspan="4">
489
- <span class="font-khmer font-bold">
490
- <%= ph.name_and_address_of_employer || 'N/A' %>
491
- </span>
492
- </td>
493
- <td colspan="4">
494
- <span class="font-khmer font-bold">
495
- <%= la.name_and_address_of_employer || 'N/A' %>
496
- </span>
497
- </td>
498
- </tr>
499
-
500
- <!-- Job Title / Salary Labels -->
501
- <% const jobFields=[ { kh: "តួនាទី និងប្រភេទនៃការងារ" , en: "Job Title and Nature of Work" , colspan: 2 }, {
502
- kh: "ប្រាក់បៀវត្សប្រចំាឆ្នាំ" , en: "Annual Salary" , colspan: 2 } ]; %>
511
+ <!-- Job Title / Salary Labels -->
512
+ <% const jobFields=[ { kh: "តួនាទី និងប្រភេទនៃការងារ" , en: "Job Title and Nature of Work" ,
513
+ colspan: 2 }, { kh: "ប្រាក់បៀវត្សប្រចំាឆ្នាំ" , en: "Annual Salary" , colspan: 2 } ]; %>
503
514
  <tr>
504
515
  <% for (let i=0; i < 2; i++) { %>
505
516
  <% jobFields.forEach(field=> { %>
@@ -510,27 +521,27 @@ exports.UW_FORM_TEMPLATE = `
510
521
  <p>
511
522
  <%= field.en %>
512
523
  </p>
513
- </td>
514
- <% }) %>
515
- <% } %>
516
- </tr>
517
-
518
- <!-- Job Title / Salary Values -->
519
- <tr>
520
- <td colspan="2"><span class="font-khmer font-bold">
521
- <%= ph.job_title %>
522
- </span></td>
523
- <td colspan="2"><span class="font-khmer font-bold">
524
- <%= ph.annual_salary %>
525
- </span></td>
526
-
527
- <td colspan="2"><span class="font-khmer font-bold">
528
- <%= la.job_title %>
529
- </span></td>
530
- <td colspan="2"><span class="font-khmer font-bold">
531
- <%= la.annual_salary %>
532
- </span></td>
533
- </tr>
524
+ </td>
525
+ <% }) %>
526
+ <% } %>
527
+ </tr>
528
+
529
+ <!-- Job Title / Salary Values -->
530
+ <tr>
531
+ <td colspan="2"><span class="font-khmer font-bold">
532
+ <%= ph.job_title %>
533
+ </span></td>
534
+ <td colspan="2"><span class="font-khmer font-bold">
535
+ <%= ph.annual_salary %>
536
+ </span></td>
537
+
538
+ <td colspan="2"><span class="font-khmer font-bold">
539
+ <%= la.job_title %>
540
+ </span></td>
541
+ <td colspan="2"><span class="font-khmer font-bold">
542
+ <%= la.annual_salary %>
543
+ </span></td>
544
+ </tr>
534
545
  <!-- USA Green Card -->
535
546
  <tr>
536
547
  <td colspan="8">
@@ -542,14 +553,14 @@ exports.UW_FORM_TEMPLATE = `
542
553
  <span>The Policyholder is not USA citizen / USA resident for tax purpose or holding
543
554
  Green
544
555
  Card.</span>
545
- </p>
546
- <%- yesNoCheckbox(ph_is_not_us_citizen) %>
547
- </td>
548
- </tr>
549
- </thead>
550
- </table>
551
- </div>
552
-
556
+ </p>
557
+ <%- yesNoCheckbox(ph_is_not_us_citizen) %>
558
+ </td>
559
+ </tr>
560
+ </thead>
561
+ </table>
562
+ </div>
563
+
553
564
  <!-- page break -->
554
565
  <div style="page-break-after: always;"></div>
555
566
  <!-- table 2 question -->
@@ -568,28 +579,28 @@ exports.UW_FORM_TEMPLATE = `
568
579
  APPLICATION FORM</h5>
569
580
  </td>
570
581
  </tr>
571
-
582
+
572
583
  <tr>
573
584
  <td colspan="3">
574
585
  <span>ព័ត៌មានអំពីរបៀបរស់នៅ និងហានិភ័យ</span> / <span>Lifestyle and Risk Information</span>
575
586
  </td>
576
587
  </tr>
577
-
588
+
578
589
  <!-- Dangerous Activities -->
579
-
590
+
580
591
  <!-- Military Flying -->
581
592
  <tr class="no-border">
582
593
  <td colspan="3">
583
594
  <p>តើលោកអ្នកកំពុង ឬមានគម្រោងធ្វើការហោះហើរជាលក្ខណៈយោធា ឬឯកជន
584
595
  ក្រៅពីអ្នកដំណើរតាមក្រុមហ៊ុនអាកាសចរណ៍ធម្មតាដែរឬទេ?</p>
585
-
596
+
586
597
  <p>Do you take part in or do you plan to take part in military or private flying other
587
598
  than as a passenger on a regular airline?</p>
588
-
599
+
589
600
  <%- yesNoCheckbox(la_lifestyle.military_or_flying) %>
590
601
  </td>
591
602
  </tr>
592
-
603
+
593
604
  <!-- Dangerous Occupations Header -->
594
605
  <tr class="no-border">
595
606
  <td colspan="3">
@@ -599,7 +610,7 @@ exports.UW_FORM_TEMPLATE = `
599
610
  pursuits?</p>
600
611
  </td>
601
612
  </tr>
602
-
613
+
603
614
  <!-- Scuba / Rock Climbing -->
604
615
  <tr class="no-border">
605
616
  <td colspan="3">
@@ -607,101 +618,101 @@ exports.UW_FORM_TEMPLATE = `
607
618
  <%- yesNoCheckbox(la_lifestyle.diving_or_climbing) %>
608
619
  </td>
609
620
  </tr>
610
-
621
+
611
622
  <!-- Parachuting / Motor Racing -->
612
623
  <tr class="no-border">
613
624
  <td colspan="3">
614
625
  <span>លោតឆ័ត្រយោង ប្រណាំងម៉ូតូ / Free fall parachuting Motor racing</span>
615
626
  <%- yesNoCheckbox(la_lifestyle.parachuting_or_racing) %>
616
- </td>
617
- </tr>
618
-
619
- <!-- Other -->
620
- <tr class="no-border">
621
- <td colspan="3">
622
- <span>ផ្សេងៗទៀត ប្រសិនបើមានសូមបញ្ជាក់ / Other if yes please provide more details : <%-
623
- renderField(la_lifestyle.activity_detail_desc) %></span>
624
- </td>
625
- </tr>
626
-
627
- <!-- Travel Abroad -->
628
- <tr class="no-border border-t border-black">
629
- <td colspan="3">
630
- <p>តើលោកអ្នកស្នាក់នៅ ឬ មានគម្រោងស្នាក់នៅក្រៅប្រទេសលើសពីរយៈពេល៣ខែ ក្នុង១ឆ្នាំដែរឬទេ?</p>
631
- <p>Do you plan to reside or travel abroad for more than three months a year?</p>
632
- <%- yesNoCheckbox(la_lifestyle.reside_or_travel_abroad) %>
633
- </td>
634
- </tr>
635
- <tr class="no-border">
636
- <td colspan="3">
637
- <p>ប្រសិនបើមានសូមផ្តល់ព័ត៌មានលម្អិតអំពីអាសយដ្ឋានរបស់ប្រទេសដែលលោកអ្នកស្នាក់នៅ ឬ
638
- មានគម្រោងស្នាក់នៅ ឬធ្វើដំណើរដូចខាងក្រោម:</p>
639
- <p class="mb-3">
627
+ </td>
628
+ </tr>
629
+
630
+ <!-- Other -->
631
+ <tr class="no-border">
632
+ <td colspan="3">
633
+ <span>ផ្សេងៗទៀត ប្រសិនបើមានសូមបញ្ជាក់ / Other if yes please provide more details : <%-
634
+ renderField(la_lifestyle.activity_detail_desc) %></span>
635
+ </td>
636
+ </tr>
637
+
638
+ <!-- Travel Abroad -->
639
+ <tr class="no-border border-t border-black">
640
+ <td colspan="3">
641
+ <p>តើលោកអ្នកស្នាក់នៅ ឬ មានគម្រោងស្នាក់នៅក្រៅប្រទេសលើសពីរយៈពេល៣ខែ ក្នុង១ឆ្នាំដែរឬទេ?</p>
642
+ <p>Do you plan to reside or travel abroad for more than three months a year?</p>
643
+ <%- yesNoCheckbox(la_lifestyle.reside_or_travel_abroad) %>
644
+ </td>
645
+ </tr>
646
+ <tr class="no-border">
647
+ <td colspan="3">
648
+ <p>ប្រសិនបើមានសូមផ្តល់ព័ត៌មានលម្អិតអំពីអាសយដ្ឋានរបស់ប្រទេសដែលលោកអ្នកស្នាក់នៅ ឬ
649
+ មានគម្រោងស្នាក់នៅ ឬធ្វើដំណើរដូចខាងក្រោម:</p>
650
+ <p class="mb-3">
640
651
  If yes, please provide detail information about address of country that reside / travel as
641
652
  following :
642
- </p>
643
- <span> <%- renderField(la_lifestyle.travel_detail_desc) %></span>
653
+ </p>
654
+ <span> <%- renderField(la_lifestyle.travel_detail_desc) %></span>
655
+ </td>
656
+ </tr>
657
+
658
+
659
+ <tr class="width-100" cellpadding="10">
660
+ <td colspan="3" style="text-align:center;" class="text-lg font-bold">
661
+ <h5>ផ្នែកទី ២: ព័ត៌មានអំពីបណ្ណសន្យារ៉ាប់រង</h5>
662
+ <h5>Part 2: INFORMATION ABOUT THE POLICY</h5>
663
+ </td>
664
+ </tr>
665
+
666
+ <!-- Policy Info Labels -->
667
+ <tr>
668
+ <td style="width:45%;">
669
+ <p>ប្រភេទបណ្ណសន្យារ៉ាប់រង និងរយៈពេលធានា</p>
670
+ <p>Type of Policy and Length of Cover</p>
671
+ </td>
672
+ <td>
673
+ <p>ទឹកប្រាក់ត្រូវបានធានា</p>
674
+ <p>(ដុល្លារអាមេរិក)</p>
675
+ <p>Sum Assured (USD)</p>
676
+ </td>
677
+ <td>
678
+ <p>បុព្វលាភធានារ៉ាប់រងដែលត្រូវបង់</p>
679
+ <p>(ដុល្លារអាមេរិក)</p>
680
+ <p>Premium Payable (USD)</p>
681
+ </td>
682
+ </tr>
683
+
684
+ <!-- Policy Info Values -->
685
+ <% policy_info.products.forEach(product=> { %>
686
+ <tr class="text-md">
687
+ <td>
688
+ <b>
689
+ <%= product.product %>
690
+ </b>
691
+ </td>
692
+ <td>
693
+ <b>
694
+ <%= product.sum_assured %>
695
+ </b>
696
+ </td>
697
+ <td>
698
+ <b>
699
+ <%= product.premium %>
700
+ </b>
701
+ </td>
702
+ </tr>
703
+ <% }) %>
704
+
705
+ <!-- Rider Details -->
706
+
707
+ <tr>
708
+ <td>
709
+ <p>
710
+ <span>អំពីគម្រោងបន្ថែម / Details of Rider: </span>
711
+ </p>
712
+ <p class="text-md font-bold">
713
+ <%= policy_info.rider.product || 'N/A' %>
714
+ </p>
644
715
  </td>
645
- </tr>
646
-
647
-
648
- <tr class="width-100" cellpadding="10">
649
- <td colspan="3" style="text-align:center;" class="text-lg font-bold">
650
- <h5>ផ្នែកទី ២: ព័ត៌មានអំពីបណ្ណសន្យារ៉ាប់រង</h5>
651
- <h5>Part 2: INFORMATION ABOUT THE POLICY</h5>
652
- </td>
653
- </tr>
654
-
655
- <!-- Policy Info Labels -->
656
- <tr>
657
- <td style="width:45%;">
658
- <p>ប្រភេទបណ្ណសន្យារ៉ាប់រង និងរយៈពេលធានា</p>
659
- <p>Type of Policy and Length of Cover</p>
660
- </td>
661
- <td>
662
- <p>ទឹកប្រាក់ត្រូវបានធានា</p>
663
- <p>(ដុល្លារអាមេរិក)</p>
664
- <p>Sum Assured (USD)</p>
665
- </td>
666
- <td>
667
- <p>បុព្វលាភធានារ៉ាប់រងដែលត្រូវបង់</p>
668
- <p>(ដុល្លារអាមេរិក)</p>
669
- <p>Premium Payable (USD)</p>
670
- </td>
671
- </tr>
672
-
673
- <!-- Policy Info Values -->
674
- <% policy_info.products.forEach(product=> { %>
675
- <tr class="text-md">
676
- <td>
677
- <b>
678
- <%= product.product %>
679
- </b>
680
- </td>
681
- <td>
682
- <b>
683
- <%= product.sum_assured %>
684
- </b>
685
- </td>
686
- <td>
687
- <b>
688
- <%= product.premium %>
689
- </b>
690
- </td>
691
- </tr>
692
- <% }) %>
693
-
694
- <!-- Rider Details -->
695
-
696
- <tr>
697
- <td>
698
- <p>
699
- <span>អំពីគម្រោងបន្ថែម / Details of Rider: </span>
700
- </p>
701
- <p class="text-md font-bold">
702
- <%= policy_info.rider.product || 'N/A' %>
703
- </p>
704
- </td>
705
716
  <td class="text-md">
706
717
  <b>
707
718
  <%= policy_info.rider.sum_assured || '-' %>
@@ -712,7 +723,7 @@ exports.UW_FORM_TEMPLATE = `
712
723
  <%= policy_info.rider.premium || '-' %>
713
724
  </b>
714
725
  </td>
715
- </tr>
726
+ </tr>
716
727
  <!-- Total Premium -->
717
728
  <tr>
718
729
  <td colspan="2" style="text-align:right;">
@@ -726,1156 +737,1163 @@ exports.UW_FORM_TEMPLATE = `
726
737
  </b>
727
738
  </td>
728
739
  </tr>
729
- </table>
730
- <!-- table 3 payment -->
731
- <table class="width-100 form-table" style="margin-top:10px;" cellpadding="10">
740
+ </table>
741
+ <!-- table 3 payment -->
742
+ <table class="width-100 form-table" style="margin-top:10px;" cellpadding="10">
743
+ <tr>
744
+
745
+ <!-- Premium Payment Label -->
746
+ <td style="vertical-align:top;width:15%;">
747
+ <p>បុព្វលាភធានារ៉ាប់រងដែលត្រូវបង់ (ជ្រើសរើស)</p>
748
+ <p>Premium Payment (select):</p>
749
+ </td>
750
+
751
+ <!-- Premium Payment Options -->
752
+ <td style="vertical-align:top;width:18%;">
753
+
754
+ <!-- Single Premium -->
755
+ <div style="display:flex;align-items:flex-start;gap:6px;margin-top:4px;">
756
+ <input type="checkbox" <%=policy_info.payment_mode==='Single' ? 'checked' : '' %>
757
+ style="margin-top:3px;flex-shrink:0;" />
758
+ <span>បុព្វលាភធានារ៉ាប់រងបង់មួយលើក / Single Premium</span>
759
+ </div>
760
+
761
+ <!-- Annually -->
762
+ <div style="display:flex;align-items:flex-start;gap:6px;margin-top:6px;">
763
+ <input type="checkbox" <%=policy_info.payment_mode==='Annually' ? 'checked' : '' %>
764
+ style="margin-top:3px;flex-shrink:0;" />
765
+ <span>ប្រចាំឆ្នាំ / Annually</span>
766
+ </div>
767
+
768
+ <!-- Semi-Annually -->
769
+ <div style="display:flex;align-items:flex-start;gap:6px;margin-top:6px;">
770
+ <input type="checkbox" <%=policy_info.payment_mode==='Semi-Annually' ? 'checked' : '' %>
771
+ style="margin-top:3px;flex-shrink:0;" />
772
+ <span>ប្រចាំឆមាស / Semi-Annually</span>
773
+ </div>
774
+
775
+ <!-- Quarterly -->
776
+ <div style="display:flex;align-items:flex-start;gap:6px;margin-top:6px;">
777
+ <input type="checkbox" <%=policy_info.payment_mode==='Quarterly' ? 'checked' : '' %>
778
+ style="margin-top:3px;flex-shrink:0;" />
779
+ <span>ប្រចាំត្រីមាស / <span>Quarterly</span></span>
780
+ </div>
781
+
782
+ <!-- Monthly -->
783
+ <div style="display:flex;align-items:flex-start;gap:6px;margin-top:6px;">
784
+ <input type="checkbox" <%=policy_info.payment_mode==='Monthly' ? 'checked' : '' %>
785
+ style="margin-top:3px;flex-shrink:0;" />
786
+ <span>ប្រចាំខែ / Monthly</span>
787
+ </div>
788
+
789
+ </td>
790
+
791
+ <!-- Method of Payment Label -->
792
+ <td style="vertical-align:top;width:12.7%;">
793
+ <p>របៀបនៃការបង់ (ជ្រើសរើស)</p>
794
+ <p>Method of Payment (select)</p>
795
+ </td>
796
+
797
+ <!-- Method of Payment Options -->
798
+ <td style="vertical-align:top;text-align:left;width:20%;">
799
+
800
+ <!-- Direct Debit -->
801
+ <div style="display:flex;align-items:flex-start;gap:6px;margin-top:4px;">
802
+ <input type="checkbox" <%=policy_info.payment_method==='Direct Debit' ? 'checked' : '' %>
803
+ style="margin-top:3px;flex-shrink:0;" />
804
+ <span>ឥណពន្ធផ្ទាល់ / <span>Direct Debit</span></span>
805
+ </div>
806
+
807
+ <!-- Bank Transfer -->
808
+ <div style="display:flex;align-items:flex-start;gap:6px;margin-top:6px;">
809
+ <input type="checkbox" <%=policy_info.payment_method==='Bank Transfer' ? 'checked' : '' %>
810
+ style="margin-top:3px;flex-shrink:0;" />
811
+ <span>ផ្ទេរតាមរយៈធនាគារ / <span>Bank Transfer</span></span>
812
+ </div>
813
+
814
+ <!-- Cheque -->
815
+ <div style="display:flex;align-items:flex-start;gap:6px;margin-top:6px;">
816
+ <input type="checkbox" <%=policy_info.payment_method==='Cheque' ? 'checked' : '' %>
817
+ style="margin-top:3px;flex-shrink:0;" />
818
+ <span>មូលប្បទានប័ត្រ / <span>Cheque</span></span>
819
+ </div>
820
+
821
+ <!-- Cash -->
822
+ <div style="display:flex;align-items:flex-start;gap:6px;margin-top:6px;">
823
+ <input type="checkbox" <%=policy_info.payment_method==='Cash' ? 'checked' : '' %>
824
+ style="margin-top:3px;flex-shrink:0;" />
825
+ <span>សាច់ប្រាក់ / <span>Cash</span></span>
826
+ </div>
827
+
828
+ <!-- Credit Card -->
829
+ <div style="display:flex;align-items:flex-start;gap:6px;margin-top:6px;">
830
+ <input type="checkbox" <%=policy_info.payment_method==='Credit Card' ? 'checked' : '' %>
831
+ style="margin-top:3px;flex-shrink:0;" />
832
+ <span>ប័ណ្ណឥណទាន / <span>Credit Card</span></span>
833
+ </div>
834
+
835
+ <!-- Other -->
836
+ <div style="display:flex;align-items:flex-start;gap:6px;margin-top:6px;">
837
+ <input type="checkbox" <%=policy_info.payment_method==='Other' ? 'checked' : '' %>
838
+ style="margin-top:3px;flex-shrink:0;" />
839
+ <span>ផ្សេងៗ / Other</span>
840
+ </div>
841
+
842
+ </td>
843
+
844
+ <!-- Direct Debit / Cheque / Credit Card Details -->
845
+ <td colspan="4" style="vertical-align:top;">
846
+
847
+ <!-- Direct Debit and Cheques -->
848
+ <div>
849
+ <p>ឥណពន្ធផ្ទាល់ និងមូលប្បទានប័ត្រ /</p>
850
+ <p>Direct Debit and Cheques:</p>
851
+ </div>
852
+
853
+ <!-- Bank Name / Cheque No -->
854
+ <div style="margin-top:4px;">
855
+ <p>សូមផ្តល់ឈ្មោះធនាគារ និងសាខាធនាគារ / លេខមូលប្បទានប័ត្រ</p>
856
+ <p>Please provide bank name and branch / cheque no.</p>
857
+ <%- policy_info.cheque_info ? '<p><u><b>' + policy_info.cheque_info + '</b></u></p>'
858
+ : '<div style="border-bottom:1px solid #000;min-height:18px;width:100%;display:block;margin-top:4px;"></div>'
859
+ %>
860
+ </div>
861
+
862
+ <!-- Credit Card Number -->
863
+ <div style="margin-top:4px;">
864
+ <p>ប័ណ្ណឥណទាន សូមផ្តល់លេខប័ណ្ណឥណទាន</p>
865
+ <p>Credit card please provide card number</p>
866
+ <%- policy_info.credit_card_info ? '<p><u><b>' + policy_info.credit_card_info + '</b></u></p>'
867
+ : '<div style="border-bottom:1px solid #000;min-height:18px;width:100%;display:block;margin-top:4px;"></div>'
868
+ %>
869
+ </div>
870
+
871
+ <!-- Card Type -->
872
+ <div style="display:flex;align-items:center;gap:12px;margin-top:4px;flex-wrap:wrap;">
873
+ <div style="display:flex;align-items:center;gap:6px;">
874
+ <input type="checkbox" <%=policy_info.credit_card_type==='Visa' ? 'checked' : '' %>
875
+ style="flex-shrink:0;"
876
+ />
877
+ <span>Visa</span>
878
+ </div>
879
+ <div style="display:flex;align-items:center;gap:6px;">
880
+ <input type="checkbox" <%=policy_info.credit_card_type==='Master' ? 'checked' : '' %>
881
+ style="flex-shrink:0;"
882
+ />
883
+ <span>Master</span>
884
+ </div>
885
+ <div style="display:flex;align-items:center;gap:6px;">
886
+ <input type="checkbox" <%=policy_info.credit_card_type==='American Express' ? 'checked' : '' %>
887
+ style="flex-shrink:0;" />
888
+ <span>American Express</span>
889
+ </div>
890
+ </div>
891
+
892
+ <!-- Expiry Date -->
893
+ <div style="margin-top:4px;">
894
+ <span>ថ្ងៃផុតកំណត់ /</span>
895
+ <span> Expiry Date:</span>
896
+ <%- policy_info.credit_card_expiry_date ? '<p><u><b>' + policy_info.credit_card_expiry_date
897
+ + '</b></u></p>'
898
+ : '<div style="border-bottom:1px solid #000;min-height:18px;width:100%;display:block;margin-top:4px;"></div>'
899
+ %>
900
+ </div>
901
+
902
+ <!-- Other Method -->
903
+ <div style="margin-top:4px;">
904
+ <span>ផ្សេងទៀត សូមបញ្ជាក់វិធីបង់ប្រាក់ /</span>
905
+ <span> Other indicate method of payment:</span>
906
+ <%- policy_info.other_payment_method_desc ? '<p><u><b>' + policy_info.other_payment_method_desc
907
+ + '</b></u></p>'
908
+ : '<div style="border-bottom:1px solid #000;min-height:18px;width:100%;display:block;margin-top:4px;"></div>'
909
+ %>
910
+ </div>
911
+ </td>
912
+ </tr>
913
+ </table>
914
+ <!-- page break -->
915
+ <div style="page-break-after: always;"></div>
916
+
917
+ <!-- table 4 beneficiaries -->
918
+ <table class="width-100 form-table" style="margin-top:10px;" cellpadding="10">
919
+ <colgroup>
920
+ <col style="width: 25%;" />
921
+ <col style="width: 5%;" />
922
+ <col style="width: 20%;" />
923
+ <col style="width: 35%;" />
924
+ <col style="width: 15%;" />
925
+ </colgroup>
926
+
927
+ <tr class="width-100" cellpadding="10">
928
+ <td colspan="5" style="text-align:center;" class="text-lg font-bold">
929
+ <h5>ផ្នែកទី៣: ព័ត៌មានរបស់អ្នកទទួលផល</h5>
930
+ <h5>Part 3: BENEFICIARIES DETAILS</h5>
931
+ </td>
932
+ </tr>
933
+
934
+ <tr class="text-start">
935
+ <td style="vertical-align: top;">
936
+ <p>
937
+ ឈ្មោះពេញរបស់អ្នកទទួលផលជាភាសាខ្មែរ និងអង់គ្លេស
938
+ </p>
939
+ <p>
940
+ Beneficiary's Full Name in Khmer and English
941
+ </p>
942
+ </td>
943
+
944
+ <td style="vertical-align: top;">
945
+ <p>អាយុ</p>
946
+ <p>Age</p>
947
+ </td>
948
+
949
+ <td style="vertical-align: top;">
950
+ <p>ទំនាក់ទំនង</p>
951
+ <p>Relationship</p>
952
+ </td>
953
+
954
+ <td style="vertical-align: top;">
955
+ <p>
956
+ លេខអត្តសញ្ញាណប័ណ្ណ/លិខិតឆ្លងដែន/សំបុត្រកំណើត
957
+ </p>
958
+ <p>
959
+ ID, Passport, Birth Certificate Number
960
+ </p>
961
+ </td>
962
+
963
+ <td style="vertical-align: top;">
964
+ <p>% នៃការបែងចែក</p>
965
+ <p>% of Share</p>
966
+ </td>
967
+ </tr>
968
+
969
+ <% beneficiaries.forEach(benefactor=> { %>
970
+ <tr>
971
+ <td>
972
+ <p> <span><b>
973
+ <%= benefactor.full_name %>
974
+ </b></span> </p>
975
+ </td>
976
+ <td>
977
+ <p> <span><b>
978
+ <%= benefactor.age %>
979
+ </b></span> </p>
980
+ </td>
981
+ <td>
982
+ <p> <span><b>
983
+ <%= benefactor.relationship %>
984
+ </b></span> </p>
985
+ </td>
986
+ <td>
987
+ <p> <span><b>
988
+ <%= benefactor.identifier_and_birth_info %>
989
+ </b></span> </p>
990
+ </td>
991
+ <td>
992
+ <p> <span><b>
993
+ <%= benefactor.percentage %>
994
+ </b></span> </p>
995
+ </td>
996
+ </tr>
997
+ <% }) %>
998
+
999
+ <tr>
1000
+ <td colspan="4" style="text-align:right">
1001
+ <span>% សរុប /</span>
1002
+ <span>Total %</span>
1003
+ </td>
1004
+ <td> <b>100%</b> </td>
1005
+ </tr>
1006
+
1007
+ <tr>
1008
+ <td colspan="5">
1009
+ <p>
1010
+ <span>
1011
+ កំណត់សម្គាល់៖ ប្រសិនបើភាគរយមិនបានបញ្ជាក់ចំនួនទឹកប្រាក់នឹងត្រូវចែកស្មើៗគ្នា /
1012
+ </span>
1013
+ <span>
1014
+ Note: If the percentage is not specified the amount will be shared equally
1015
+ </span>
1016
+ </p>
1017
+ </td>
1018
+ </tr>
1019
+ </table>
1020
+ <!-- table 5 existing insurance -->
1021
+ <table class="width-100 form-table" style="margin-top:10px;" cellpadding="10">
1022
+ <colgroup>
1023
+ <col style="width: 60%;" />
1024
+ <col style="width: 20%;" />
1025
+ <col style="width: 20%;" />
1026
+ </colgroup>
1027
+ <tr class="width-100" cellpadding="10">
1028
+ <td colspan="3" style="text-align:center;" class="text-lg font-bold">
1029
+ <h5>សេចក្ដីប្រកាសអំពីបណ្ណសន្យារ៉ាប់រងដែលមាន</h5>
1030
+ <h5>DECLARATION OF ANY EXISTING INSURANCE POLICIES</h5>
1031
+ </td>
1032
+ </tr>
1033
+
1034
+ <tr>
1035
+ <td colspan="3">
1036
+ <p class="mb-2">
1037
+ <span>
1038
+ តើលោកអ្នកមានបណ្ណសន្យារ៉ាប់រងដែរឬទេ / Do you have any existing insurance policies?
1039
+ </span>
1040
+ <%- yesNoCheckbox(existing_insurance_info.has_existing_insurance) %>
1041
+ </p>
1042
+ <p class="mt-2">
1043
+ <span>
1044
+ ប្រសិនបើមាន សូមផ្ដល់ព័ត៍មានដូចខាងក្រោម / If yes, please provide the following information:
1045
+ <!-- <div class="form-field-line"> -->
1046
+ </span>
1047
+ </p>
1048
+ </td>
1049
+ </tr>
1050
+
1051
+ <tr>
1052
+ <td style="vertical-align: top;">
1053
+ <p>
1054
+ ឈ្មោះរបស់ក្រុមហ៊ុនធានារ៉ាប់រង
1055
+ </p>
1056
+ <p>
1057
+ Name of Insurance Company
1058
+ </p>
1059
+ </td>
1060
+ <td style="vertical-align: top;">
1061
+ <p>
1062
+ ប្រភេទបណ្ណសន្យារ៉ាប់រងដែលលោកអ្នកមាន
1063
+ </p>
1064
+ <p>
1065
+ Type of Policy You Currently Have
1066
+ </p>
1067
+ </td>
1068
+ <td style="vertical-align: top;">
1069
+ <p>
1070
+ ទឹកប្រាក់ត្រូវបានធានាសរុប
1071
+ </p>
1072
+ <p>
1073
+ The Total Amount Insured (USD)
1074
+ </p>
1075
+ </td>
1076
+ </tr>
1077
+
1078
+ <% existing_insurance_info.existing_policy_info.forEach(exist_pilicy=> { %>
1079
+ <tr>
1080
+ <td><b>
1081
+ <%= exist_pilicy.insurance_company %>
1082
+ </b></td>
1083
+ <td><b>
1084
+ <%= exist_pilicy.type_of_policy %>
1085
+ </b></td>
1086
+ <td><b>
1087
+ <%= exist_pilicy.sum_assured %>
1088
+ </b></td>
1089
+ </tr>
1090
+ <% }) %>
1091
+
1092
+ <% if (existing_insurance_info.existing_policy_info.length===0) { %>
732
1093
  <tr>
733
-
734
- <!-- Premium Payment Label -->
735
- <td style="vertical-align:top;width:15%;">
736
- <p>បុព្វលាភធានារ៉ាប់រងដែលត្រូវបង់ (ជ្រើសរើស)</p>
737
- <p>Premium Payment (select):</p>
738
- </td>
739
-
740
- <!-- Premium Payment Options -->
741
- <td style="vertical-align:top;width:18%;">
742
-
743
- <!-- Single Premium -->
744
- <div style="display:flex;align-items:flex-start;gap:6px;margin-top:4px;">
745
- <input type="checkbox" <%=policy_info.payment_mode==='Single' ? 'checked' : '' %>
746
- style="margin-top:3px;flex-shrink:0;" />
747
- <span>បុព្វលាភធានារ៉ាប់រងបង់មួយលើក / Single Premium</span>
748
- </div>
749
-
750
- <!-- Annually -->
751
- <div style="display:flex;align-items:flex-start;gap:6px;margin-top:6px;">
752
- <input type="checkbox" <%=policy_info.payment_mode==='Annually' ? 'checked' : '' %>
753
- style="margin-top:3px;flex-shrink:0;" />
754
- <span>ប្រចាំឆ្នាំ / Annually</span>
755
- </div>
756
-
757
- <!-- Semi-Annually -->
758
- <div style="display:flex;align-items:flex-start;gap:6px;margin-top:6px;">
759
- <input type="checkbox" <%=policy_info.payment_mode==='Semi-Annually' ? 'checked' : '' %>
760
- style="margin-top:3px;flex-shrink:0;" />
761
- <span>ប្រចាំឆមាស / Semi-Annually</span>
762
- </div>
763
-
764
- <!-- Quarterly -->
765
- <div style="display:flex;align-items:flex-start;gap:6px;margin-top:6px;">
766
- <input type="checkbox" <%=policy_info.payment_mode==='Quarterly' ? 'checked' : '' %>
767
- style="margin-top:3px;flex-shrink:0;" />
768
- <span>ប្រចាំត្រីមាស / <span>Quarterly</span></span>
769
- </div>
770
-
771
- <!-- Monthly -->
772
- <div style="display:flex;align-items:flex-start;gap:6px;margin-top:6px;">
773
- <input type="checkbox" <%=policy_info.payment_mode==='Monthly' ? 'checked' : '' %>
774
- style="margin-top:3px;flex-shrink:0;" />
775
- <span>ប្រចាំខែ / Monthly</span>
776
- </div>
777
-
778
- </td>
779
-
780
- <!-- Method of Payment Label -->
781
- <td style="vertical-align:top;width:12.7%;">
782
- <p>របៀបនៃការបង់ (ជ្រើសរើស)</p>
783
- <p>Method of Payment (select)</p>
784
- </td>
785
-
786
- <!-- Method of Payment Options -->
787
- <td style="vertical-align:top;text-align:left;width:20%;">
788
-
789
- <!-- Direct Debit -->
790
- <div style="display:flex;align-items:flex-start;gap:6px;margin-top:4px;">
791
- <input type="checkbox" <%=policy_info.payment_method==='Direct Debit' ? 'checked' : '' %>
792
- style="margin-top:3px;flex-shrink:0;" />
793
- <span>ឥណពន្ធផ្ទាល់ / <span>Direct Debit</span></span>
794
- </div>
795
-
796
- <!-- Bank Transfer -->
797
- <div style="display:flex;align-items:flex-start;gap:6px;margin-top:6px;">
798
- <input type="checkbox" <%=policy_info.payment_method==='Bank Transfer' ? 'checked' : '' %>
799
- style="margin-top:3px;flex-shrink:0;" />
800
- <span>ផ្ទេរតាមរយៈធនាគារ / <span>Bank Transfer</span></span>
801
- </div>
802
-
803
- <!-- Cheque -->
804
- <div style="display:flex;align-items:flex-start;gap:6px;margin-top:6px;">
805
- <input type="checkbox" <%=policy_info.payment_method==='Cheque' ? 'checked' : '' %>
806
- style="margin-top:3px;flex-shrink:0;" />
807
- <span>មូលប្បទានប័ត្រ / <span>Cheque</span></span>
808
- </div>
809
-
810
- <!-- Cash -->
811
- <div style="display:flex;align-items:flex-start;gap:6px;margin-top:6px;">
812
- <input type="checkbox" <%=policy_info.payment_method==='Cash' ? 'checked' : '' %>
813
- style="margin-top:3px;flex-shrink:0;" />
814
- <span>សាច់ប្រាក់ / <span>Cash</span></span>
815
- </div>
816
-
817
- <!-- Credit Card -->
818
- <div style="display:flex;align-items:flex-start;gap:6px;margin-top:6px;">
819
- <input type="checkbox" <%=policy_info.payment_method==='Credit Card' ? 'checked' : '' %>
820
- style="margin-top:3px;flex-shrink:0;" />
821
- <span>ប័ណ្ណឥណទាន / <span>Credit Card</span></span>
822
- </div>
823
-
824
- <!-- Other -->
825
- <div style="display:flex;align-items:flex-start;gap:6px;margin-top:6px;">
826
- <input type="checkbox" <%=policy_info.payment_method==='Other' ? 'checked' : '' %>
827
- style="margin-top:3px;flex-shrink:0;" />
828
- <span>ផ្សេងៗ / Other</span>
829
- </div>
830
-
831
- </td>
832
-
833
- <!-- Direct Debit / Cheque / Credit Card Details -->
834
- <td colspan="4" style="vertical-align:top;">
835
-
836
- <!-- Direct Debit and Cheques -->
837
- <div>
838
- <p>ឥណពន្ធផ្ទាល់ និងមូលប្បទានប័ត្រ /</p>
839
- <p>Direct Debit and Cheques:</p>
840
- </div>
841
-
842
- <!-- Bank Name / Cheque No -->
843
- <div style="margin-top:4px;">
844
- <p>សូមផ្តល់ឈ្មោះធនាគារ និងសាខាធនាគារ / លេខមូលប្បទានប័ត្រ</p>
845
- <p>Please provide bank name and branch / cheque no.</p>
846
- <%- policy_info.cheque_info ? '<p><u><b>' + policy_info.cheque_info + '</b></u></p>'
847
- : '<div style="border-bottom:1px solid #000;min-height:18px;width:100%;display:block;margin-top:4px;"></div>'
848
- %>
849
- </div>
850
-
851
- <!-- Credit Card Number -->
852
- <div style="margin-top:4px;">
853
- <p>ប័ណ្ណឥណទាន សូមផ្តល់លេខប័ណ្ណឥណទាន</p>
854
- <p>Credit card please provide card number</p>
855
- <%- policy_info.credit_card_info ? '<p><u><b>' + policy_info.credit_card_info + '</b></u></p>'
856
- : '<div style="border-bottom:1px solid #000;min-height:18px;width:100%;display:block;margin-top:4px;"></div>'
857
- %>
858
- </div>
859
-
860
- <!-- Card Type -->
861
- <div style="display:flex;align-items:center;gap:12px;margin-top:4px;flex-wrap:wrap;">
862
- <div style="display:flex;align-items:center;gap:6px;">
863
- <input type="checkbox" <%=policy_info.credit_card_type==='Visa' ? 'checked' : '' %>
864
- style="flex-shrink:0;"
865
- />
866
- <span>Visa</span>
867
- </div>
868
- <div style="display:flex;align-items:center;gap:6px;">
869
- <input type="checkbox" <%=policy_info.credit_card_type==='Master' ? 'checked' : '' %>
870
- style="flex-shrink:0;"
871
- />
872
- <span>Master</span>
873
- </div>
874
- <div style="display:flex;align-items:center;gap:6px;">
875
- <input type="checkbox" <%=policy_info.credit_card_type==='American Express' ? 'checked' : '' %>
876
- style="flex-shrink:0;" />
877
- <span>American Express</span>
878
- </div>
879
- </div>
880
-
881
- <!-- Expiry Date -->
882
- <div style="margin-top:4px;">
883
- <span>ថ្ងៃផុតកំណត់ /</span>
884
- <span> Expiry Date:</span>
885
- <%- policy_info.credit_card_expiry_date ? '<p><u><b>' + policy_info.credit_card_expiry_date + '</b></u></p>'
886
- : '<div style="border-bottom:1px solid #000;min-height:18px;width:100%;display:block;margin-top:4px;"></div>'
887
- %>
888
- </div>
889
-
890
- <!-- Other Method -->
891
- <div style="margin-top:4px;">
892
- <span>ផ្សេងទៀត សូមបញ្ជាក់វិធីបង់ប្រាក់ /</span>
893
- <span> Other indicate method of payment:</span>
894
- <%- policy_info.other_payment_method_desc ? '<p><u><b>' + policy_info.other_payment_method_desc + '</b></u></p>'
895
- : '<div style="border-bottom:1px solid #000;min-height:18px;width:100%;display:block;margin-top:4px;"></div>'
896
- %>
897
- </div>
898
- </td>
899
- </tr>
900
- </table>
901
- <!-- page break -->
902
- <div style="page-break-after: always;"></div>
903
-
904
- <!-- table 4 beneficiaries -->
905
- <table class="width-100 form-table" style="margin-top:10px;" cellpadding="10">
906
- <colgroup>
907
- <col style="width: 25%;" />
908
- <col style="width: 5%;" />
909
- <col style="width: 20%;" />
910
- <col style="width: 35%;" />
911
- <col style="width: 15%;" />
912
- </colgroup>
913
-
914
- <tr class="width-100" cellpadding="10">
915
- <td colspan="5" style="text-align:center;" class="text-lg font-bold">
916
- <h5>ផ្នែកទី៣: ព័ត៌មានរបស់អ្នកទទួលផល</h5>
917
- <h5>Part 3: BENEFICIARIES DETAILS</h5>
918
- </td>
1094
+ <td class="height-25">&nbsp;</td>
1095
+ <td>&nbsp;</td>
1096
+ <td>&nbsp;</td>
919
1097
  </tr>
920
-
921
- <tr class="text-start">
922
- <td style="vertical-align: top;">
923
- <p>
924
- ឈ្មោះពេញរបស់អ្នកទទួលផលជាភាសាខ្មែរ និងអង់គ្លេស
925
- </p>
926
- <p>
927
- Beneficiary's Full Name in Khmer and English
928
- </p>
929
- </td>
930
-
931
- <td style="vertical-align: top;">
932
- <p>អាយុ</p>
933
- <p>Age</p>
934
- </td>
935
-
936
- <td style="vertical-align: top;">
937
- <p>ទំនាក់ទំនង</p>
938
- <p>Relationship</p>
939
- </td>
940
-
941
- <td style="vertical-align: top;">
942
- <p>
943
- លេខអត្តសញ្ញាណប័ណ្ណ/លិខិតឆ្លងដែន/សំបុត្រកំណើត
944
- </p>
945
- <p>
946
- ID, Passport, Birth Certificate Number
947
- </p>
948
- </td>
949
-
950
- <td style="vertical-align: top;">
951
- <p>% នៃការបែងចែក</p>
952
- <p>% of Share</p>
953
- </td>
1098
+ <tr>
1099
+ <td class="height-25">&nbsp;</td>
1100
+ <td>&nbsp;</td>
1101
+ <td>&nbsp;</td>
954
1102
  </tr>
955
-
956
- <% beneficiaries.forEach(benefactor=> { %>
957
- <tr>
958
- <td>
959
- <p> <span><b>
960
- <%= benefactor.full_name %>
961
- </b></span> </p>
962
- </td>
963
- <td>
964
- <p> <span><b>
965
- <%= benefactor.age %>
966
- </b></span> </p>
967
- </td>
968
- <td>
969
- <p> <span><b>
970
- <%= benefactor.relationship %>
971
- </b></span> </p>
972
- </td>
973
- <td>
974
- <p> <span><b>
975
- <%= benefactor.identifier_and_birth_info %>
976
- </b></span> </p>
977
- </td>
978
- <td>
979
- <p> <span><b>
980
- <%= benefactor.percentage %>
981
- </b></span> </p>
982
- </td>
983
- </tr>
984
- <% }) %>
985
-
986
- <tr>
987
- <td colspan="4" style="text-align:right">
988
- <span>% សរុប /</span>
989
- <span>Total %</span>
990
- </td>
991
- <td> <b>100%</b> </td>
992
- </tr>
993
-
994
- <tr>
995
- <td colspan="5">
996
- <p>
997
- <span>
998
- កំណត់សម្គាល់៖ ប្រសិនបើភាគរយមិនបានបញ្ជាក់ចំនួនទឹកប្រាក់នឹងត្រូវចែកស្មើៗគ្នា /
999
- </span>
1000
- <span>
1001
- Note: If the percentage is not specified the amount will be shared equally
1002
- </span>
1003
- </p>
1004
- </td>
1005
- </tr>
1006
- </table>
1007
- <!-- table 5 existing insurance -->
1008
- <table class="width-100 form-table" style="margin-top:10px;" cellpadding="10">
1103
+ <% } %>
1104
+
1105
+ </tbody>
1106
+ </table>
1107
+ <!-- iMPORTANT Remark-->
1108
+ <h4 class="font-bold text-lg mt-5 underline">ចំណាំ​ / IMPORTANT ៖</h4>
1109
+
1110
+ <div class="my-2 space-y-2">
1111
+ <p>
1112
+ យើងខ្ញុំសូមណែនាំលោកអ្នកមិនគួរផ្លាស់ប្តូរបណ្ណសន្យារ៉ាប់រងអាយុជីវិតដែលមានស្រាប់ជាមួយនឹងបណ្ណសន្យារ៉ាប់រងថ្មី។
1113
+ គុណវិបត្តិមួយចំនួនគឺ៖
1114
+ </p>
1115
+ <p>
1116
+ We advise you not to replace an existing life insurance policy with a new one. Some disadvantages are:
1117
+ </p>
1118
+
1119
+ <ol style="list-style-type: decimal; padding-left: 30px; margin: 0;">
1120
+ <li style="margin-bottom: 6px;">
1121
+ លោកអ្នកអាចនឹងមិនទទួលបានការធានារ៉ាប់រងតាមលក្ខខណ្ឌទូទៅ /
1122
+ You may not be insurable on standard terms
1123
+ </li>
1124
+
1125
+ <li style="margin-bottom: 6px;">
1126
+ លោកអ្នកអាចនឹងត្រូវបង់បុព្វលាភធានារ៉ាប់រងខ្ពស់ជាងបច្ចុប្បន្នដោយសារពេលនេះអ្នកមានអាយុច្រើនជាងមុន /
1127
+ You may have to pay a higher premium as you are now older
1128
+ </li>
1129
+
1130
+ <li>
1131
+ លោកអ្នកអាចនឹងបាត់បង់កំណើនអត្ថប្រយោជន៍ហិរញ្ញវត្ថុដែលមានក្នុងឆ្នាំកន្លងមក /
1132
+ You may lose financial benefits built up over the years
1133
+ </li>
1134
+ </ol>
1135
+ <p>
1136
+ សូមពិគ្រោះជាមួយក្រុមហ៊ុនធានារ៉ាប់រងបច្ចុប្បន្នរបស់លោកអ្នក មុននឹងធ្វើការសម្រេចចិត្ត។
1137
+ សូមធ្វើការប្រៀបធៀបដោយប្រុងប្រយ័ត្នដើម្បីប្រាកដថាលោកអ្នកកំពុងធ្វើការ
1138
+ សម្រេចចិត្តដែលល្អបំផុតសម្រាប់អត្ថប្រយោជន៍របស់លោកអ្នក។
1139
+ </p>
1140
+ <p>
1141
+ Please consult your current insurer before making a final decision. Make a careful comparison so that
1142
+ you
1143
+ can be sure you are making a decision that is in your best interest.
1144
+ </p>
1145
+
1146
+ <p>
1147
+ តើមានធានារ៉ាប់រងណាមួយដែលលោកអ្នកកំពុងស្នើសុំដើម្បីជំនួស
1148
+ ឬមានបំណងជំនួសដូចបានរៀបរាប់ខាងលើដែរឬទេ?
1149
+ </p>
1150
+ <p>
1151
+ Is the insurance you are applying for to replace, or intended to replace, any of the policies listed
1152
+ above?
1153
+ </p>
1154
+ <%- yesNoCheckbox(existing_insurance_info.is_intended_to_replace) %>
1155
+
1156
+ <p>ប្រសិនបើមាន មួយណា? / If yes, which one?
1157
+ </p>
1158
+
1159
+ <%- renderField(existing_insurance_info.replacement_detail_desc ) %>
1160
+
1161
+ <p>
1162
+ <span>យើងខ្ញុំត្រូវការព័ត៌មាននេះដើម្បីផ្តល់ដំណឹងដល់ក្រុមហ៊ុនធានារ៉ាប់រងបច្ចុប្បន្នរបស់លោកអ្នក(ប្រសិនបើមាន)ថាលោកអ្នកអាចនឹងសម្រេចចិត្តផ្លាស់ប្តូរបណ្ណសន្យារ៉ាប់រង។</span>
1163
+ <span>
1164
+ We need this information as we are required to inform your existing insurer-if you have one-that
1165
+ you
1166
+ may be
1167
+ replacing
1168
+ the policy.
1169
+ </span>
1170
+ </p>
1171
+ <span>
1172
+ តើលោកអ្នកមានការស្នើសុំ
1173
+ ឬពាក្យស្នើសុំការធានារ៉ាប់រងអាយុជីវិតណាមួយដែលត្រូវបានបដិសេធ ពន្យារពេល
1174
+ ឬទទួលយកក្រោមលក្ខខណ្ឌពិសេសដោយក្រុមហ៊ុនធានារ៉ាប់រងណាមួយផ្សេងទៀតដែរឬទេ?
1175
+ ប្រសិនបើមានសូមផ្តល់ព័ត៌មានលម្អិតដូចខាងក្រោម
1176
+ </span>
1177
+
1178
+ <%- yesNoCheckbox(existing_insurance_info.is_rejected_by_other_insurer) %>
1179
+
1180
+ <p>
1181
+ Has any proposal or application for a Life Insurance policy of any kind ever been refused,
1182
+ postponed,
1183
+ or accepted at special terms by any other insurer? If yes, please provide details below:
1184
+ </p>
1185
+ </div>
1186
+
1187
+ <table style="width:100%; table-layout:fixed; border-collapse:collapse;" cellpadding="10"
1188
+ class="form-table">
1189
+ <colgroup>
1190
+ <col style="width: 25%;" />
1191
+ <col style="width: 25%;" />
1192
+ <col style="width: 25%;" />
1193
+ <col style="width: 25%;" />
1194
+ </colgroup>
1195
+ <tr>
1196
+ <td>
1197
+ <p>ឈ្មោះរបស់ក្រុមហ៊ុនធានារ៉ាប់រង</p>
1198
+ <p>Name of Insurance Company</p>
1199
+ </td>
1200
+
1201
+ <td class="td-width-100">
1202
+ <p>
1203
+ <b>
1204
+ <%= existing_insurance_info.rejected_insurance_company %>
1205
+ </b>
1206
+ </p>
1207
+ </td>
1208
+
1209
+ <td>
1210
+ <p>ប្រភេទបណ្ណសន្យារ៉ាប់រង</p>
1211
+ <p>Type of Policy</p>
1212
+ </td>
1213
+
1214
+ <td class="td-width-100">
1215
+ <p>
1216
+ <b>
1217
+ <%= existing_insurance_info.rejected_policy_type %>
1218
+ </b>
1219
+ </p>
1220
+ </td>
1221
+ </tr>
1222
+
1223
+ <tr>
1224
+ <td>
1225
+ <span>មូលហេតុ </span>
1226
+ <span>Reasons Given</span>
1227
+ </td>
1228
+
1229
+ <td colspan="3">
1230
+ <p>
1231
+ <b>
1232
+ <%= existing_insurance_info.rejected_reason %>
1233
+ </b>
1234
+ </p>
1235
+ </td>
1236
+ </tr>
1237
+ </table>
1238
+ <!-- page break -->
1239
+ <div style="page-break-after: always;"></div>
1240
+
1241
+ <!-- Part 7 Health Questions-->
1242
+ <table class="width-100 form-table" style="margin-top:10px;" cellpadding="10">
1243
+
1244
+ <tr class="width-100" cellpadding="10">
1245
+ <td colspan="3" style="text-align:center;" class="text-lg font-bold">
1246
+ <h5>ផ្នែកទី៤: ព័ត៌មានពាក់ព័ន្ធនឹងសុខភាព</h5>
1247
+ <h5>Part 4: HEALTH-RELATED QUESTIONS</h5>
1248
+ </td>
1249
+ </tr>
1250
+
1251
+ <tr>
1252
+ <td style="width:35%;" class="align-top">
1253
+ <table style="border-collapse: collapse; width: 100%; border: none;">
1009
1254
  <colgroup>
1255
+ <col style="width: 40%;" />
1010
1256
  <col style="width: 60%;" />
1011
- <col style="width: 20%;" />
1012
- <col style="width: 20%;" />
1013
1257
  </colgroup>
1014
- <tr class="width-100" cellpadding="10">
1015
- <td colspan="3" style="text-align:center;" class="text-lg font-bold">
1016
- <h5>សេចក្ដីប្រកាសអំពីបណ្ណសន្យារ៉ាប់រងដែលមាន</h5>
1017
- <h5>DECLARATION OF ANY EXISTING INSURANCE POLICIES</h5>
1018
- </td>
1019
- </tr>
1020
-
1021
1258
  <tr>
1022
- <td colspan="3">
1023
- <p class="mb-2">
1024
- <span>
1025
- តើលោកអ្នកមានបណ្ណសន្យារ៉ាប់រងដែរឬទេ / Do you have any existing insurance policies?
1026
- </span>
1027
- <%- yesNoCheckbox(existing_insurance_info.has_existing_insurance) %>
1028
- </p>
1029
- <p class="mt-2">
1030
- <span>
1031
- ប្រសិនបើមាន សូមផ្ដល់ព័ត៍មានដូចខាងក្រោម / If yes, please provide the following information:
1032
- <!-- <div class="form-field-line"> -->
1033
- </span>
1034
- </p>
1259
+ <td style="white-space: nowrap; border: none;">
1260
+ <span>កម្ពស់ / Height:</span>
1261
+ </td>
1262
+ <td style="border: none;">
1263
+ <b>
1264
+ <u>
1265
+ <span class="font-eng font-bold">
1266
+ <%= health_info.height %> ស.ម / cm
1267
+ </span>
1268
+ </u>
1269
+ </b>
1035
1270
  </td>
1036
1271
  </tr>
1037
-
1038
1272
  <tr>
1039
- <td style="vertical-align: top;">
1040
- <p>
1041
- ឈ្មោះរបស់ក្រុមហ៊ុនធានារ៉ាប់រង
1042
- </p>
1043
- <p>
1044
- Name of Insurance Company
1045
- </p>
1046
- </td>
1047
- <td style="vertical-align: top;">
1048
- <p>
1049
- ប្រភេទបណ្ណសន្យារ៉ាប់រងដែលលោកអ្នកមាន
1050
- </p>
1051
- <p>
1052
- Type of Policy You Currently Have
1053
- </p>
1273
+ <td style="white-space: nowrap; border: none;">
1274
+ <span>ទម្ងន់ / Weight:</span>
1054
1275
  </td>
1055
- <td style="vertical-align: top;">
1056
- <p>
1057
- ទឹកប្រាក់ត្រូវបានធានាសរុប
1058
- </p>
1059
- <p>
1060
- The Total Amount Insured (USD)
1061
- </p>
1276
+ <td style="border: none;">
1277
+ <b><u>
1278
+ <span class="font-eng font-bold">
1279
+ <%= health_info.weight %>
1280
+ </span>
1281
+ <span> គ.ក្រ / kg</span>
1282
+ </u></b>
1062
1283
  </td>
1063
1284
  </tr>
1064
-
1065
- <% existing_insurance_info.existing_policy_info.forEach(exist_pilicy=> { %>
1066
- <tr>
1067
- <td><b>
1068
- <%= exist_pilicy.insurance_company %>
1069
- </b></td>
1070
- <td><b>
1071
- <%= exist_pilicy.type_of_policy %>
1072
- </b></td>
1073
- <td><b>
1074
- <%= exist_pilicy.sum_assured %>
1075
- </b></td>
1076
- </tr>
1077
- <% }) %>
1078
-
1079
- <% if (existing_insurance_info.existing_policy_info.length===0) { %>
1080
- <tr>
1081
- <td class="height-25">&nbsp;</td>
1082
- <td>&nbsp;</td>
1083
- <td>&nbsp;</td>
1084
- </tr>
1085
- <tr>
1086
- <td class="height-25">&nbsp;</td>
1087
- <td>&nbsp;</td>
1088
- <td>&nbsp;</td>
1089
- </tr>
1090
- <% } %>
1091
-
1092
- </tbody>
1093
1285
  </table>
1094
- <!-- iMPORTANT Remark-->
1095
- <h4 class="font-bold text-lg mt-5 underline">ចំណាំ​ / IMPORTANT ៖</h4>
1096
-
1097
- <div class="my-2 space-y-2">
1098
- <p>
1099
- យើងខ្ញុំសូមណែនាំលោកអ្នកមិនគួរផ្លាស់ប្តូរបណ្ណសន្យារ៉ាប់រងអាយុជីវិតដែលមានស្រាប់ជាមួយនឹងបណ្ណសន្យារ៉ាប់រងថ្មី។
1100
- គុណវិបត្តិមួយចំនួនគឺ៖
1101
- </p>
1102
- <p>
1103
- We advise you not to replace an existing life insurance policy with a new one. Some disadvantages are:
1104
- </p>
1105
-
1106
- <ol style="list-style-type: decimal; padding-left: 30px; margin: 0;">
1107
- <li style="margin-bottom: 6px;">
1108
- លោកអ្នកអាចនឹងមិនទទួលបានការធានារ៉ាប់រងតាមលក្ខខណ្ឌទូទៅ /
1109
- You may not be insurable on standard terms
1110
- </li>
1111
-
1112
- <li style="margin-bottom: 6px;">
1113
- លោកអ្នកអាចនឹងត្រូវបង់បុព្វលាភធានារ៉ាប់រងខ្ពស់ជាងបច្ចុប្បន្នដោយសារពេលនេះអ្នកមានអាយុច្រើនជាងមុន /
1114
- You may have to pay a higher premium as you are now older
1115
- </li>
1116
-
1117
- <li>
1118
- លោកអ្នកអាចនឹងបាត់បង់កំណើនអត្ថប្រយោជន៍ហិរញ្ញវត្ថុដែលមានក្នុងឆ្នាំកន្លងមក /
1119
- You may lose financial benefits built up over the years
1120
- </li>
1121
- </ol>
1122
- <p>
1123
- សូមពិគ្រោះជាមួយក្រុមហ៊ុនធានារ៉ាប់រងបច្ចុប្បន្នរបស់លោកអ្នក មុននឹងធ្វើការសម្រេចចិត្ត។
1124
- សូមធ្វើការប្រៀបធៀបដោយប្រុងប្រយ័ត្នដើម្បីប្រាកដថាលោកអ្នកកំពុងធ្វើការ
1125
- សម្រេចចិត្តដែលល្អបំផុតសម្រាប់អត្ថប្រយោជន៍របស់លោកអ្នក។
1126
- </p>
1127
- <p>
1128
- Please consult your current insurer before making a final decision. Make a careful comparison so that
1129
- you
1130
- can be sure you are making a decision that is in your best interest.
1131
- </p>
1132
-
1133
- <p>
1134
- តើមានធានារ៉ាប់រងណាមួយដែលលោកអ្នកកំពុងស្នើសុំដើម្បីជំនួស
1135
- ឬមានបំណងជំនួសដូចបានរៀបរាប់ខាងលើដែរឬទេ?
1136
- </p>
1137
- <p>
1138
- Is the insurance you are applying for to replace, or intended to replace, any of the policies listed
1139
- above?
1140
- </p>
1141
- <%- yesNoCheckbox(existing_insurance_info.is_intended_to_replace) %>
1142
-
1143
- <p>ប្រសិនបើមាន មួយណា? / If yes, which one?
1144
- </p>
1145
-
1146
- <%- renderField(existing_insurance_info.replacement_detail_desc ) %>
1147
-
1148
- <p>
1149
- <span>យើងខ្ញុំត្រូវការព័ត៌មាននេះដើម្បីផ្តល់ដំណឹងដល់ក្រុមហ៊ុនធានារ៉ាប់រងបច្ចុប្បន្នរបស់លោកអ្នក(ប្រសិនបើមាន)ថាលោកអ្នកអាចនឹងសម្រេចចិត្តផ្លាស់ប្តូរបណ្ណសន្យារ៉ាប់រង។</span>
1150
- <span>
1151
- We need this information as we are required to inform your existing insurer-if you have one-that
1152
- you
1153
- may be
1154
- replacing
1155
- the policy.
1156
- </span>
1157
- </p>
1158
- <span>
1159
- តើលោកអ្នកមានការស្នើសុំ
1160
- ឬពាក្យស្នើសុំការធានារ៉ាប់រងអាយុជីវិតណាមួយដែលត្រូវបានបដិសេធ ពន្យារពេល
1161
- ឬទទួលយកក្រោមលក្ខខណ្ឌពិសេសដោយក្រុមហ៊ុនធានារ៉ាប់រងណាមួយផ្សេងទៀតដែរឬទេ?
1162
- ប្រសិនបើមានសូមផ្តល់ព័ត៌មានលម្អិតដូចខាងក្រោម
1163
- </span>
1164
-
1165
- <%- yesNoCheckbox(existing_insurance_info.is_rejected_by_other_insurer) %>
1166
-
1167
- <p>
1168
- Has any proposal or application for a Life Insurance policy of any kind ever been refused,
1169
- postponed,
1170
- or accepted at special terms by any other insurer? If yes, please provide details below:
1171
- </p>
1172
- </div>
1173
-
1174
- <table style="width:100%; table-layout:fixed; border-collapse:collapse;" cellpadding="10" class="form-table">
1175
- <colgroup>
1176
- <col style="width: 25%;" />
1177
- <col style="width: 25%;" />
1178
- <col style="width: 25%;" />
1179
- <col style="width: 25%;" />
1180
- </colgroup>
1181
- <tr>
1182
- <td>
1183
- <p>ឈ្មោះរបស់ក្រុមហ៊ុនធានារ៉ាប់រង</p>
1184
- <p>Name of Insurance Company</p>
1185
- </td>
1186
-
1187
- <td class="td-width-100">
1188
- <p>
1189
- <b>
1190
- <%= existing_insurance_info.rejected_insurance_company %>
1191
- </b>
1192
- </p>
1193
- </td>
1194
-
1195
- <td>
1196
- <p>ប្រភេទបណ្ណសន្យារ៉ាប់រង</p>
1197
- <p>Type of Policy</p>
1198
- </td>
1199
-
1200
- <td class="td-width-100">
1201
- <p>
1202
- <b>
1203
- <%= existing_insurance_info.rejected_policy_type %>
1204
- </b>
1205
- </p>
1206
- </td>
1207
- </tr>
1208
-
1209
- <tr>
1210
- <td>
1211
- <span>មូលហេតុ </span>
1212
- <span>Reasons Given</span>
1213
- </td>
1214
-
1215
- <td colspan="3">
1216
- <p>
1217
- <b>
1218
- <%= existing_insurance_info.rejected_reason %>
1219
- </b>
1220
- </p>
1221
- </td>
1222
- </tr>
1223
- </table>
1224
- <!-- page break -->
1225
- <div style="page-break-after: always;"></div>
1226
-
1227
- <!-- Part 7 Health Questions-->
1228
- <table class="width-100 form-table" style="margin-top:10px;" cellpadding="10">
1229
-
1230
- <tr class="width-100" cellpadding="10">
1231
- <td colspan="3" style="text-align:center;" class="text-lg font-bold">
1232
- <h5>ផ្នែកទី៤: ព័ត៌មានពាក់ព័ន្ធនឹងសុខភាព</h5>
1233
- <h5>Part 4: HEALTH-RELATED QUESTIONS</h5>
1234
- </td>
1235
- </tr>
1236
-
1237
- <tr>
1238
- <td style="width:35%;" class="align-top">
1239
- <table style="border-collapse: collapse; width: 100%; border: none;">
1240
- <colgroup>
1241
- <col style="width: 40%;" />
1242
- <col style="width: 60%;" />
1243
- </colgroup>
1244
- <tr>
1245
- <td style="white-space: nowrap; border: none;">
1246
- <span>កម្ពស់ / Height:</span>
1247
- </td>
1248
- <td style="border: none;">
1249
- <b>
1250
- <u>
1251
- <span class="font-eng font-bold">
1252
- <%= health_info.height %> ស.ម / cm
1253
- </span>
1254
- </u>
1255
- </b>
1256
- </td>
1257
- </tr>
1258
- <tr>
1259
- <td style="white-space: nowrap; border: none;">
1260
- <span>ទម្ងន់ / Weight:</span>
1261
- </td>
1262
- <td style="border: none;">
1263
- <b><u>
1264
- <span class="font-eng font-bold">
1265
- <%= health_info.weight %>
1266
- </span>
1267
- <span> គ.ក្រ / kg</span>
1268
- </u></b>
1269
- </td>
1270
- </tr>
1271
- </table>
1272
- </td>
1273
-
1274
- <td class="align-top">
1275
- <p>
1276
- <span>
1277
- តើមានការផ្លាស់ប្តូរទម្ងន់ក្នុងកំឡុងពេល ៦ ខែឬទេ? / Any weight changes during the past 6 month?
1278
- </span>
1279
- <%- yesNoCheckbox( health_info.is_weight_changed) %>
1280
- </p>
1281
- </td>
1282
- </tr>
1283
-
1284
- <tr>
1285
- <td class="align-top">
1286
- <p>
1287
- តើលោកអ្នកពិសារបារីដែរឬទេ? / Do you smoke?
1288
- </p>
1289
- <%- yesNoCheckbox(health_info.is_smoke) %>
1290
- </td>
1291
-
1292
- <td class="align-top">
1293
- <p>
1294
- ប្រសិនបើមាន តើប៉ុន្មានដើមក្នុងមួយថ្ងៃ? / If yes, How many cigarettes per day?
1295
- </p>
1296
- <%- renderField(health_info.smoke_detail) %>
1297
- </td>
1298
- </tr>
1299
-
1300
- <tr>
1301
- <td class="align-top">
1302
- <p>
1303
- Have you ever taken any kind of addictive substance/drugs?
1304
- តើអ្នកធ្លាប់ប្រើប្រាស់សារធាតុញៀន ឬថ្នាំញៀនដែរឬទេ? /
1305
- </p>
1306
- <%- yesNoCheckbox(health_info.is_drug_or_substance) %>
1307
- </td>
1308
-
1309
- <td class="align-top space-y-3">
1310
- <p>
1311
- If yes, please state:
1312
- ប្រសិនបើមាន សូមបញ្ជាក់ដូចខាងក្រោម /
1313
- </p>
1314
-
1315
- <p>
1316
- <span>
1317
- (ក). ប្រភេទថ្នាំ / Type of drug
1318
- <%- renderField(health_info.drug_type) %>
1319
- </span>
1320
- </p>
1321
-
1322
- <p>
1323
- <span>
1324
- (ខ). រយៈពេលប្រើប្រាស់ / For how long?
1325
- <%- renderField(health_info.drug_duration) %>
1326
- </span>
1327
- </p>
1328
-
1329
- <p>
1330
- <span>
1331
- (គ). តើលោកអ្នកបានឈប់ប្រើប្រាស់ហើយឬនៅ? / Have you stopped?
1332
- <%- renderField(health_info.drug_stopped) %>
1333
- </span>
1334
- </p>
1335
-
1336
- </td>
1337
- </tr>
1338
-
1286
+ </td>
1287
+
1288
+ <td class="align-top">
1289
+ <p>
1290
+ <span>
1291
+ តើមានការផ្លាស់ប្តូរទម្ងន់ក្នុងកំឡុងពេល ៦ ខែឬទេ? / Any weight changes during the past 6 month?
1292
+ </span>
1293
+ <%- yesNoCheckbox( health_info.is_weight_changed) %>
1294
+ </p>
1295
+ </td>
1296
+ </tr>
1297
+
1298
+ <tr>
1299
+ <td class="align-top">
1300
+ <p>
1301
+ តើលោកអ្នកពិសារបារីដែរឬទេ? / Do you smoke?
1302
+ </p>
1303
+ <%- yesNoCheckbox(health_info.is_smoke) %>
1304
+ </td>
1305
+
1306
+ <td class="align-top">
1307
+ <p>
1308
+ ប្រសិនបើមាន តើប៉ុន្មានដើមក្នុងមួយថ្ងៃ? / If yes, How many cigarettes per day?
1309
+ </p>
1310
+ <%- renderField(health_info.smoke_detail) %>
1311
+ </td>
1312
+ </tr>
1313
+
1314
+ <tr>
1315
+ <td class="align-top">
1316
+ <p>
1317
+ Have you ever taken any kind of addictive substance/drugs?
1318
+ តើអ្នកធ្លាប់ប្រើប្រាស់សារធាតុញៀន ឬថ្នាំញៀនដែរឬទេ? /
1319
+ </p>
1320
+ <%- yesNoCheckbox(health_info.is_drug_or_substance) %>
1321
+ </td>
1322
+
1323
+ <td class="align-top space-y-3">
1324
+ <p>
1325
+ If yes, please state:
1326
+ ប្រសិនបើមាន សូមបញ្ជាក់ដូចខាងក្រោម /
1327
+ </p>
1328
+
1329
+ <p>
1330
+ <span>
1331
+ (ក). ប្រភេទថ្នាំ / Type of drug
1332
+ <%- renderField(health_info.drug_type) %>
1333
+ </span>
1334
+ </p>
1335
+
1336
+ <p>
1337
+ <span>
1338
+ (ខ). រយៈពេលប្រើប្រាស់ / For how long?
1339
+ <%- renderField(health_info.drug_duration) %>
1340
+ </span>
1341
+ </p>
1342
+
1343
+ <p>
1344
+ <span>
1345
+ (គ). តើលោកអ្នកបានឈប់ប្រើប្រាស់ហើយឬនៅ? / Have you stopped?
1346
+ <%- renderField(health_info.drug_stopped) %>
1347
+ </span>
1348
+ </p>
1349
+
1350
+ </td>
1351
+ </tr>
1352
+
1353
+ <tr>
1354
+ <td class="align-top">
1355
+ <p>
1356
+ តើលោកអ្នកពិសារគ្រឿងស្រវឹងដែរឬទេ? / Do you drink alcohol?
1357
+ </p>
1358
+ <%- yesNoCheckbox(health_info.is_alcohol) %>
1359
+ </td>
1360
+
1361
+ <td>
1362
+ <p>
1363
+ ប្រសិនបើមាន តើញឹកញាប់ដែរឬទេ? / If yes, how often?
1364
+ </p>
1365
+ <p>
1366
+ សូមបញ្ជាក់បរិមាណដែលបានពិសារក្នុងមួយសប្តាហ៍ / Please specify amount of drink per week.
1367
+ <%- renderField(health_info.alcohol_detail) %>
1368
+ </p>
1369
+ </td>
1370
+ </tr>
1371
+ </table>
1372
+ <div class="space-y-2 my-3">
1373
+ <p class="text-justify">តើលោកអ្នកមានឪពុកម្តាយ ឬបងប្អូនបង្កើត មានជំងឺ ឬទទួលមរណភាពដោយសារ៖ ជំងឺវង្វេង
1374
+ (Alzheimer's
1375
+ disease) ជំងឺមហារីក
1376
+ (Cancer) ជំងឺជាលិកាមហារីកមិនទាន់រាលដាល (Carcinoma in situ) ជំងឺផ្លូវចិត្ត (Mental illness)
1377
+ ជំងឺទឹកនោមផ្អែម
1378
+ (Diabetes) ជំងឺតម្រងនោម (polycystic kidney disease) ជំងឺដាច់សរសៃឈាមខួរក្បាល (Stroke)
1379
+ ការឡើងសម្ពាធឈាមខ្ពស់
1380
+ (High
1381
+ blood pressure) ជំងឺបេះដូង (Heart Disease) ឬជំងឺតំណពូជដទៃទៀត (Hereditary disease) ដែរឬទេ?</p>
1382
+
1383
+ <p class="text-justify">Have any of your biological parents or siblings been diagnosed with or passed
1384
+ away as
1385
+ a
1386
+ result
1387
+ of: Alzheimer's
1388
+ disease, cancer, carcinoma in situ, mental illness, diabetes, polycystic kidney disease, stroke, high
1389
+ blood
1390
+ pressure, heart disease, or any other hereditary disease?</p>
1391
+
1392
+ <%- yesNoCheckbox(health_info.is_hereditary_disease) %>
1393
+
1394
+ <p class="mb-3">ប្រសិនបើមាន សូមផ្ដល់ព័ត៌មានលម្អិតដូចខាងក្រោម / If yes, please provide details below:
1395
+ </p>
1396
+ </div>
1397
+
1398
+ <table style="width:100%; table-layout:fixed; border-collapse:collapse;" cellpadding="10"
1399
+ class="form-table">
1400
+ <colgroup>
1401
+ <col style="width: 25%;" />
1402
+ <col style="width: 25%;" />
1403
+ <col style="width: 25%;" />
1404
+ <col style="width: 25%;" />
1405
+ </colgroup>
1406
+ <tr>
1407
+ <td>
1408
+ <p>ឈ្មោះរបស់សាច់ញាតិ</p>
1409
+ <p>Name of Relative</p>
1410
+ </td>
1411
+
1412
+ <td>
1413
+ <p>ទំនាក់ទំនងជាមួយលោកអ្នក</p>
1414
+ <p>Relationship to you</p>
1415
+ </td>
1416
+
1417
+ <td>
1418
+ <p>ជម្ងឺ</p>
1419
+ <p>Illness</p>
1420
+ </td>
1421
+
1422
+ <td>
1423
+ <p>រស់នៅ ឬទទួលមរណៈភាព</p>
1424
+ <p>Living or Deceased?</p>
1425
+ </td>
1426
+ </tr>
1427
+
1428
+ <% health_info.hereditary_relative_info.forEach(hereditary=> { %>
1429
+ <tr>
1430
+ <td><b>
1431
+ <%= hereditary.full_name %>
1432
+ </b></td>
1433
+ <td><b>
1434
+ <%= hereditary.relationship %>
1435
+ </b></td>
1436
+ <td><b>
1437
+ <%= hereditary.illness %>
1438
+ </b></td>
1439
+ <td><b>
1440
+ <%= hereditary.living_or_deceased %>
1441
+ </b></td>
1442
+ </tr>
1443
+ <% }) %>
1444
+
1445
+ <% if (health_info.hereditary_relative_info.length===0) { %>
1339
1446
  <tr>
1340
- <td class="align-top">
1341
- <p>
1342
- តើលោកអ្នកពិសារគ្រឿងស្រវឹងដែរឬទេ? / Do you drink alcohol?
1343
- </p>
1344
- <%- yesNoCheckbox(health_info.is_alcohol) %>
1345
- </td>
1346
-
1347
- <td>
1348
- <p>
1349
- ប្រសិនបើមាន តើញឹកញាប់ដែរឬទេ? / If yes, how often?
1350
- </p>
1351
- <p>
1352
- សូមបញ្ជាក់បរិមាណដែលបានពិសារក្នុងមួយសប្តាហ៍ / Please specify amount of drink per week.
1353
- <%- renderField(health_info.alcohol_detail) %>
1354
- </p>
1355
- </td>
1447
+ <td class="height-25">&nbsp;</td>
1448
+ <td>&nbsp;</td>
1449
+ <td>&nbsp;</td>
1450
+ <td>&nbsp;</td>
1356
1451
  </tr>
1357
- </table>
1358
- <div class="space-y-2 my-3">
1359
- <p class="text-justify">តើលោកអ្នកមានឪពុកម្តាយ ឬបងប្អូនបង្កើត មានជំងឺ ឬទទួលមរណភាពដោយសារ៖ ជំងឺវង្វេង
1360
- (Alzheimer's
1361
- disease) ជំងឺមហារីក
1362
- (Cancer) ជំងឺជាលិកាមហារីកមិនទាន់រាលដាល (Carcinoma in situ) ជំងឺផ្លូវចិត្ត (Mental illness)
1363
- ជំងឺទឹកនោមផ្អែម
1364
- (Diabetes) ជំងឺតម្រងនោម (polycystic kidney disease) ជំងឺដាច់សរសៃឈាមខួរក្បាល (Stroke)
1365
- ការឡើងសម្ពាធឈាមខ្ពស់
1366
- (High
1367
- blood pressure) ជំងឺបេះដូង (Heart Disease) ឬជំងឺតំណពូជដទៃទៀត (Hereditary disease) ដែរឬទេ?</p>
1368
-
1369
- <p class="text-justify">Have any of your biological parents or siblings been diagnosed with or passed
1370
- away as
1371
- a
1372
- result
1373
- of: Alzheimer's
1374
- disease, cancer, carcinoma in situ, mental illness, diabetes, polycystic kidney disease, stroke, high
1375
- blood
1376
- pressure, heart disease, or any other hereditary disease?</p>
1377
-
1378
- <%- yesNoCheckbox(health_info.is_hereditary_disease) %>
1379
-
1380
- <p class="mb-3">ប្រសិនបើមាន សូមផ្ដល់ព័ត៌មានលម្អិតដូចខាងក្រោម / If yes, please provide details below:
1452
+ <% } %>
1453
+ </table>
1454
+ </div>
1455
+
1456
+ <div id="questions-source">
1457
+ <!-- Additional Questions-->
1458
+ <table class="table w-full table-fixed border-collapse form-table" cellpadding="10">
1459
+
1460
+ <colgroup>
1461
+ <col style="width: 45%;" />
1462
+ <col style="width: 10%;" />
1463
+ <col style="width: 10%;" />
1464
+ <col style="width: 35%;" />
1465
+ </colgroup>
1466
+
1467
+ <!-- Header -->
1468
+ <tr class="width-100" cellpadding="10">
1469
+ <td colspan="4" style="text-align:center;" class="text-lg font-bold">
1470
+ <h5>សំណួរបន្ថែម</h5>
1471
+ <h5>ADDITIONAL QUESTIONS</h5>
1472
+ </td>
1473
+ </tr>
1474
+
1475
+ <!-- Sub-header -->
1476
+ <tr>
1477
+ <td rowspan="2" class="align-top">
1478
+ <p>
1479
+ 1.តើលោកអ្នកធ្លាប់បានទទួលការព្យាបាលជំងឺ ឬមានរោគសញ្ញាណមួយដូចខាងក្រោមដែរឬទេ?
1480
+ </p>
1481
+ <p>
1482
+ Have you ever had or treated for any of the following conditions or symptoms?
1483
+ </p>
1484
+ </td>
1485
+ <td colspan="2" class="text-center align-top">
1486
+ <span>សូមគូស / Please Tick</span>
1487
+ </td>
1488
+ <td rowspan="2" class="align-top">
1489
+ <p>
1490
+ ប្រសិនបើមាន សូមផ្តល់ព័ត៌មានលម្អិតខាងក្រោម
1491
+ </p>
1492
+ <p>
1493
+ If yes, please provide more details:
1494
+ </p>
1495
+ </td>
1496
+ </tr>
1497
+
1498
+ <!-- Question 1 -->
1499
+ <tr>
1500
+ <td style="width:10%; text-align: center; vertical-align: middle;">
1501
+ <p>មាន / Yes</p>
1502
+ </td>
1503
+ <td style="width:10%; text-align: center; vertical-align: middle;">
1504
+ <p>មិនមាន / No</p>
1505
+ </td>
1506
+ </tr>
1507
+
1508
+ <% const additionalQuestions=health_info.additional_question_info; const questionNumbers=Array.from({
1509
+ length: 17 }, (_, i)=> i + 2); // q2 - q18
1510
+ %>
1511
+
1512
+ <% questionNumbers.forEach(num=> { %>
1513
+ <tr class="question-row">
1514
+ <td class="align-top space-y-2 text-justify">
1515
+ <p>
1516
+ <%= num %>.
1517
+ <%= additionalQuestions['q' + num + '_question_kh'] %>
1381
1518
  </p>
1382
- </div>
1383
-
1384
- <table style="width:100%; table-layout:fixed; border-collapse:collapse;" cellpadding="10" class="form-table">
1385
- <colgroup>
1386
- <col style="width: 25%;" />
1387
- <col style="width: 25%;" />
1388
- <col style="width: 25%;" />
1389
- <col style="width: 25%;" />
1390
- </colgroup>
1391
- <tr>
1392
- <td>
1393
- <p>ឈ្មោះរបស់សាច់ញាតិ</p>
1394
- <p>Name of Relative</p>
1395
- </td>
1396
-
1397
- <td>
1398
- <p>ទំនាក់ទំនងជាមួយលោកអ្នក</p>
1399
- <p>Relationship to you</p>
1400
- </td>
1401
-
1402
- <td>
1403
- <p>ជម្ងឺ</p>
1404
- <p>Illness</p>
1405
- </td>
1406
-
1407
- <td>
1408
- <p>រស់នៅ ឬទទួលមរណៈភាព</p>
1409
- <p>Living or Deceased?</p>
1410
- </td>
1411
- </tr>
1412
-
1413
- <% health_info.hereditary_relative_info.forEach(hereditary=> { %>
1414
- <tr>
1415
- <td><b>
1416
- <%= hereditary.full_name %>
1417
- </b></td>
1418
- <td><b>
1419
- <%= hereditary.relationship %>
1420
- </b></td>
1421
- <td><b>
1422
- <%= hereditary.illness %>
1423
- </b></td>
1424
- <td><b>
1425
- <%= hereditary.living_or_deceased %>
1426
- </b></td>
1427
- </tr>
1428
- <% }) %>
1429
-
1430
- <% if (health_info.hereditary_relative_info.length===0) { %>
1431
- <tr>
1432
- <td class="height-25">&nbsp;</td>
1433
- <td>&nbsp;</td>
1434
- <td>&nbsp;</td>
1435
- <td>&nbsp;</td>
1436
- </tr>
1437
- <% } %>
1438
- </table>
1439
- </div>
1440
-
1441
- <div id="questions-source">
1442
- <!-- Additional Questions-->
1443
- <table class="table w-full table-fixed border-collapse form-table" cellpadding="10">
1444
-
1445
- <colgroup>
1446
- <col style="width: 45%;" />
1447
- <col style="width: 10%;" />
1448
- <col style="width: 10%;" />
1449
- <col style="width: 35%;" />
1450
- </colgroup>
1451
-
1452
- <!-- Header -->
1453
- <tr class="width-100" cellpadding="10">
1454
- <td colspan="4" style="text-align:center;" class="text-lg font-bold">
1455
- <h5>សំណួរបន្ថែម</h5>
1456
- <h5>ADDITIONAL QUESTIONS</h5>
1457
- </td>
1458
- </tr>
1459
-
1460
- <!-- Sub-header -->
1461
- <tr>
1462
- <td rowspan="2" class="align-top">
1463
- <p>
1464
- 1.តើលោកអ្នកធ្លាប់បានទទួលការព្យាបាលជំងឺ ឬមានរោគសញ្ញាណមួយដូចខាងក្រោមដែរឬទេ?
1465
- </p>
1466
- <p>
1467
- Have you ever had or treated for any of the following conditions or symptoms?
1468
- </p>
1469
- </td>
1470
- <td colspan="2" class="text-center align-top">
1471
- <span>សូមគូស / Please Tick</span>
1472
- </td>
1473
- <td rowspan="2" class="align-top">
1474
- <p>
1475
- ប្រសិនបើមាន សូមផ្តល់ព័ត៌មានលម្អិតខាងក្រោម
1476
- </p>
1477
- <p>
1478
- If yes, please provide more details:
1479
- </p>
1480
- </td>
1481
- </tr>
1482
-
1483
- <!-- Question 1 -->
1484
- <tr>
1485
- <td style="width:10%; text-align: center; vertical-align: middle;">
1486
- <p>មាន / Yes</p>
1487
- </td>
1488
- <td style="width:10%; text-align: center; vertical-align: middle;">
1489
- <p>មិនមាន / No</p>
1490
- </td>
1491
- </tr>
1492
-
1493
- <% const additionalQuestions=health_info.additional_question_info; const questionNumbers=Array.from({ length: 17 },
1494
- (_, i)=> i + 2); // q2 - q18
1495
- %>
1496
-
1497
- <% questionNumbers.forEach(num=> { %>
1498
- <tr class="question-row">
1499
- <td class="align-top space-y-2 text-justify">
1500
- <p>
1501
- <%= num %>.
1502
- <%= additionalQuestions['q' + num + '_question_kh'] %>
1503
- </p>
1504
- <p class="text-justify">
1505
- <%= additionalQuestions['q' + num + '_question_en'] %>
1506
- </p>
1507
- </td>
1508
-
1509
- <td style="text-align:center; vertical-align:middle;">
1510
- <%- renderCheck(additionalQuestions['q' + num], true) %>
1511
- </td>
1512
-
1513
- <td style="text-align:center; vertical-align:middle;">
1514
- <%- renderCheck(additionalQuestions['q' + num], false) %>
1515
- </td>
1516
- <td class="text-justify align-top">
1517
- <div>
1518
- <p>
1519
- <%= additionalQuestions['q' + num + '_detail'] || '' %>
1520
- </p>
1521
- </div>
1522
- </td>
1523
- </tr>
1524
- <% }) %>
1525
- </table>
1526
-
1527
- <div class="question-row declaration-header">
1528
- <table class="table w-full table-fixed border-collapse form-table" cellpadding="20">
1529
- <tr>
1530
- <td colspan="4" style="text-align:center;" class="text-lg font-bold">
1531
- <h5>សេចក្តីប្រកាសរបស់អ្នកស្នើសុំ</h5>
1532
- <h5>DECLARATION BY THE APPLICANT</h5>
1533
- </td>
1534
- </tr>
1535
- </table>
1536
-
1537
- <!-- Declaration by the application-->
1538
- <div class="mt-5 space-y-3 text-justify">
1539
- <p>ខ្លឹមសារនៃពាក្យស្នើសុំនេះត្រូវបានពន្យល់យ៉ាងច្បាស់ហើយខ្ញុំបានយល់ទាំងស្រុង។​</p>
1540
- <p>The contents of this application have been explained to me, and I have fully understood them. </p>
1541
- <p>
1542
- ខ្ញុំសូមបញ្ជាក់ថា
1543
- ចម្លើយដែលផ្តល់ជូននៅក្នុងឯកសារនេះពិតជាត្រឹមត្រូវទោះបីជាត្រូវបានបំពេញដោយខ្ញុំឬដោយអ្នកផ្សេងទៀតក្នុងនាម
1544
- របស់ខ្ញុំក៏ដោយខ្ញុំទទួលខុសត្រូវទាំងស្រុងចំពោះព័ត៌មានទាំងនោះហើយខ្ញុំមិនបានលាក់បាំងព័ត៌មានអ្វីទាំងអស់។
1545
- </p>
1546
- <p>
1547
- I confirm that the answers provided in this
1548
- document are true, and whether written by me or anyone else on my behalf I
1549
- accept full responsibility for them, and that I have not withheld any material
1550
- information.
1551
- </p>
1552
- <p>
1553
- ខ្ញុំយល់ស្របថានឹងមិនមានការទទួលខុសត្រូវណាមួយពីក្រុមហ៊ុន
1554
- <span class="font-bold text-lg">ហ្វីលីព ឡាយហ្វ៍ អាសួរេន (ខេមបូឌា) ម.ក </span>
1555
- រហូតទាល់តែបណ្ណសន្យា
1556
- រ៉ាប់រងនេះត្រូវបានចេញនិងប្រគល់ជូនខ្ញុំហើយបុព្វលាភធានារ៉ាប់រងដំបូងបានបង់។រាល់ការទូទាត់បុព្វលាភធានារ៉ាប់រងទៅឲ្យម្ចាស់បណ្ណសន្យារ៉ាប់រង
1557
- ឬអ្នកស្នើសុំធានារ៉ាប់រងនឹងត្រូវធ្វើឡើងតាមរយៈឯកសារព័ត៌មានធនាគារដែលបានភ្ជាប់ក្នុងអំឡុងពេល
1558
- ដាក់ពាក្យស្នើសុំធានារ៉ាប់រងនេះប្រសិនបើគ្មានការផ្ដល់ព័ត៌មានធនាគារថ្មីណាមួយមកកាន់ក្រុមហ៊ុន។
1559
- </p>
1560
- </p>
1561
- <p>I agree that there shall be no liability upon
1562
- <span class="font-bold text-lg">Phillip Life Assurance (Cambodia) Plc</span>. until a policy has
1563
- been issued and
1564
- delivered to me and the first premium is paid in full. All premium to be refunded to Policyholders
1565
- or Applicants will
1566
- be made through the bank information given
1567
- during an application process, if no latest bank information has been provided and received by the
1568
- company.
1569
- </p>
1570
- <p>
1571
- ខ្ញុំយល់ព្រម និងផ្តល់សិទ្ធិឲ្យស្ថាប័នវេជ្ជសាស្ត្រ
1572
- ការិយាល័យរបស់ក្រុមហ៊ុនធានារ៉ាប់រង
1573
- ឬក្រុមហ៊ុនធានារ៉ាប់រងអាយុជីវិតដទៃទៀត ដើម្បីប្រគល់ទៅឲ្យក្រុមហ៊ុនធានារ៉ាប់រង
1574
- <span class="font-bold text-lg">ហ្វីលីព ឡាយហ្វ៍ អាសួរេន (ខេមបូឌា) ម.ក</span>
1575
- នូវព័ត៌មានទាក់ទងនឹងខ្ញុំ
1576
- គ្រប់ពេលដោយមិនគិតពីលទ្ធផលនៃពាក្យស្នើសុំរបស់ខ្ញុំឡើយ។
1577
- </p>
1578
- <p>And I also agree and authorise (a) any
1579
- medical source, insurance office, or other Life Insurance company to release to
1580
- <span class="font-bold text-lg">Phillip Life Assurance (Cambodia) Plc.</span> any relevant
1581
- information concerning me
1582
- at
1583
- any time, regardless of the outcome of my application.
1584
- </p>
1519
+ <p class="text-justify">
1520
+ <%= additionalQuestions['q' + num + '_question_en'] %>
1521
+ </p>
1522
+ </td>
1523
+
1524
+ <td style="text-align:center; vertical-align:middle;">
1525
+ <%- renderCheck(additionalQuestions['q' + num], true) %>
1526
+ </td>
1527
+
1528
+ <td style="text-align:center; vertical-align:middle;">
1529
+ <%- renderCheck(additionalQuestions['q' + num], false) %>
1530
+ </td>
1531
+ <td class="text-justify align-top">
1532
+ <div>
1585
1533
  <p>
1586
- ខ្ញុំអនុញ្ញាត និងយល់ព្រមឲ្យក្រុមហ៊ុនប្រើប្រាស់ព័ត៌មាន​
1587
- និងទិន្នន័យទាំងស្រុងដែលខ្ញុំបានផ្ដល់នៅក្នុងពាក្យស្នើសុំរបស់ខ្ញុំ
1588
- ក្នុងគោលបំណងស្របតាមច្បាប់ដូចជាការផ្សព្វផ្សាយទីផ្សារ ការសិក្សាទីផ្សារ និងការបម្រើអតិថិជនដោយក្រុមហ៊ុន
1589
- សម្ព័ន្ធក្រុមហ៊ុន ឬជាដៃគូពាណិជ្ជកម្មរបស់ក្រុមហ៊ុនដោយមិនចាំបាច់មានការយល់ព្រម
1590
- និងជូនដំណឹងបន្ថែមពីខ្ញុំឡើយ។
1591
- ក្រុមហ៊ុនមិនត្រូវបានអនុញ្ញាតឲ្យបញ្ចេញព័ត៌មានណាមួយទៅភាគីទីបីណាមួយឬប្រើប្រាស់ព័ត៌មាននោះសម្រាប់គោលបំណងផ្សេងទៀតដែលមិនទាក់ទងនឹងគោលបំណងទាំងឡាយខាងលើឡើយ
1592
- ប្រសិនបើគ្មានការយល់ព្រមព្រៀងជាលាយលក្ខណ៍អក្សរនោះ។
1593
- </p>
1594
- <p style="margin-bottom:5px">
1595
- I authorize and consent the Company to use all of my information provided in my application form
1596
- in legal purpose such as marketing, market survey and customer service by company, affiliate,
1597
- or business partner without my prior consent or notification. The Company shall not allow to
1598
- disclose any information of any other purpose not related to above mentioned purpose without prior
1599
- consent in written.
1534
+ <%= additionalQuestions['q' + num + '_detail'] || '' %>
1600
1535
  </p>
1601
1536
  </div>
1602
- </div>
1603
-
1604
- <div class="question-row declaration-header">
1605
- <table class="width-100 form-table" style="margin-top: 10px;" cellpadding="15">
1606
- <tbody>
1607
- <tr class="text-start-top">
1608
- <!-- Policyholder -->
1609
- <td width="50%">
1610
- <div style="
1537
+ </td>
1538
+ </tr>
1539
+ <% }) %>
1540
+ </table>
1541
+
1542
+ <div class="question-row declaration-header">
1543
+ <table class="table w-full table-fixed border-collapse form-table" cellpadding="20">
1544
+ <tr>
1545
+ <td colspan="4" style="text-align:center;" class="text-lg font-bold">
1546
+ <h5>សេចក្តីប្រកាសរបស់អ្នកស្នើសុំ</h5>
1547
+ <h5>DECLARATION BY THE APPLICANT</h5>
1548
+ </td>
1549
+ </tr>
1550
+ </table>
1551
+
1552
+ <!-- Declaration by the application-->
1553
+ <div class="mt-5 space-y-3 text-justify">
1554
+ <p>ខ្លឹមសារនៃពាក្យស្នើសុំនេះត្រូវបានពន្យល់យ៉ាងច្បាស់ហើយខ្ញុំបានយល់ទាំងស្រុង។​</p>
1555
+ <p>The contents of this application have been explained to me, and I have fully understood them. </p>
1556
+ <p>
1557
+ ខ្ញុំសូមបញ្ជាក់ថា
1558
+ ចម្លើយដែលផ្តល់ជូននៅក្នុងឯកសារនេះពិតជាត្រឹមត្រូវទោះបីជាត្រូវបានបំពេញដោយខ្ញុំឬដោយអ្នកផ្សេងទៀតក្នុងនាម
1559
+ របស់ខ្ញុំក៏ដោយខ្ញុំទទួលខុសត្រូវទាំងស្រុងចំពោះព័ត៌មានទាំងនោះហើយខ្ញុំមិនបានលាក់បាំងព័ត៌មានអ្វីទាំងអស់។
1560
+ </p>
1561
+ <p>
1562
+ I confirm that the answers provided in this
1563
+ document are true, and whether written by me or anyone else on my behalf I
1564
+ accept full responsibility for them, and that I have not withheld any material
1565
+ information.
1566
+ </p>
1567
+ <p>
1568
+ ខ្ញុំយល់ស្របថានឹងមិនមានការទទួលខុសត្រូវណាមួយពីក្រុមហ៊ុន
1569
+ <span class="font-bold text-lg">ហ្វីលីព ឡាយហ្វ៍ អាសួរេន (ខេមបូឌា) ម.ក </span>
1570
+ រហូតទាល់តែបណ្ណសន្យា
1571
+ រ៉ាប់រងនេះត្រូវបានចេញនិងប្រគល់ជូនខ្ញុំហើយបុព្វលាភធានារ៉ាប់រងដំបូងបានបង់។រាល់ការទូទាត់បុព្វលាភធានារ៉ាប់រងទៅឲ្យម្ចាស់បណ្ណសន្យារ៉ាប់រង
1572
+ ឬអ្នកស្នើសុំធានារ៉ាប់រងនឹងត្រូវធ្វើឡើងតាមរយៈឯកសារព័ត៌មានធនាគារដែលបានភ្ជាប់ក្នុងអំឡុងពេល
1573
+ ដាក់ពាក្យស្នើសុំធានារ៉ាប់រងនេះប្រសិនបើគ្មានការផ្ដល់ព័ត៌មានធនាគារថ្មីណាមួយមកកាន់ក្រុមហ៊ុន។
1574
+ </p>
1575
+ </p>
1576
+ <p>I agree that there shall be no liability upon
1577
+ <span class="font-bold text-lg">Phillip Life Assurance (Cambodia) Plc</span>. until a policy has
1578
+ been issued and
1579
+ delivered to me and the first premium is paid in full. All premium to be refunded to Policyholders
1580
+ or Applicants will
1581
+ be made through the bank information given
1582
+ during an application process, if no latest bank information has been provided and received by the
1583
+ company.
1584
+ </p>
1585
+ <p>
1586
+ ខ្ញុំយល់ព្រម និងផ្តល់សិទ្ធិឲ្យស្ថាប័នវេជ្ជសាស្ត្រ
1587
+ ការិយាល័យរបស់ក្រុមហ៊ុនធានារ៉ាប់រង
1588
+ ឬក្រុមហ៊ុនធានារ៉ាប់រងអាយុជីវិតដទៃទៀត ដើម្បីប្រគល់ទៅឲ្យក្រុមហ៊ុនធានារ៉ាប់រង
1589
+ <span class="font-bold text-lg">ហ្វីលីព ឡាយហ្វ៍ អាសួរេន (ខេមបូឌា) ម.ក</span>
1590
+ នូវព័ត៌មានទាក់ទងនឹងខ្ញុំ
1591
+ គ្រប់ពេលដោយមិនគិតពីលទ្ធផលនៃពាក្យស្នើសុំរបស់ខ្ញុំឡើយ។
1592
+ </p>
1593
+ <p>And I also agree and authorise (a) any
1594
+ medical source, insurance office, or other Life Insurance company to release to
1595
+ <span class="font-bold text-lg">Phillip Life Assurance (Cambodia) Plc.</span> any relevant
1596
+ information concerning me
1597
+ at
1598
+ any time, regardless of the outcome of my application.
1599
+ </p>
1600
+ <p>
1601
+ ខ្ញុំអនុញ្ញាត និងយល់ព្រមឲ្យក្រុមហ៊ុនប្រើប្រាស់ព័ត៌មាន​
1602
+ និងទិន្នន័យទាំងស្រុងដែលខ្ញុំបានផ្ដល់នៅក្នុងពាក្យស្នើសុំរបស់ខ្ញុំ
1603
+ ក្នុងគោលបំណងស្របតាមច្បាប់ដូចជាការផ្សព្វផ្សាយទីផ្សារ ការសិក្សាទីផ្សារ និងការបម្រើអតិថិជនដោយក្រុមហ៊ុន
1604
+ សម្ព័ន្ធក្រុមហ៊ុន ឬជាដៃគូពាណិជ្ជកម្មរបស់ក្រុមហ៊ុនដោយមិនចាំបាច់មានការយល់ព្រម
1605
+ និងជូនដំណឹងបន្ថែមពីខ្ញុំឡើយ។
1606
+ ក្រុមហ៊ុនមិនត្រូវបានអនុញ្ញាតឲ្យបញ្ចេញព័ត៌មានណាមួយទៅភាគីទីបីណាមួយឬប្រើប្រាស់ព័ត៌មាននោះសម្រាប់គោលបំណងផ្សេងទៀតដែលមិនទាក់ទងនឹងគោលបំណងទាំងឡាយខាងលើឡើយ
1607
+ ប្រសិនបើគ្មានការយល់ព្រមព្រៀងជាលាយលក្ខណ៍អក្សរនោះ។
1608
+ </p>
1609
+ <p style="margin-bottom:5px">
1610
+ I authorize and consent the Company to use all of my information provided in my application form
1611
+ in legal purpose such as marketing, market survey and customer service by company, affiliate,
1612
+ or business partner without my prior consent or notification. The Company shall not allow to
1613
+ disclose any information of any other purpose not related to above mentioned purpose without prior
1614
+ consent in written.
1615
+ </p>
1616
+ </div>
1617
+ </div>
1618
+
1619
+ <div class="question-row declaration-header">
1620
+ <table class="width-100 form-table" style="margin-top: 10px;" cellpadding="15">
1621
+ <tbody>
1622
+ <tr class="text-start-top">
1623
+ <!-- Policyholder -->
1624
+ <td width="50%">
1625
+ <div style="
1611
1626
  display: flex;
1612
1627
  flex-direction: column;
1613
1628
  justify-content: space-between;
1614
1629
  min-height: 250px;
1615
1630
  text-align: left; /* change to left */
1616
1631
  ">
1617
- <div>
1618
- <p style="margin:0;">
1619
- ហត្ថលេខា ឬស្នាមមេដៃរបស់ម្ចាស់បណ្ណសន្យារ៉ាប់រង
1620
- </p>
1621
- <p style="margin:0;">
1622
- Signature or thumb print of Policyholder
1623
- </p>
1624
- </div>
1625
- <div class="flex items-center gap-2 w-full">
1626
- <span>ហត្ថលេខា ឬស្នាមមេដៃ / Signature or thumb print</span>
1627
-
1628
- <div class="flex-1 border-b border-black min-h-[18px] mt-1"></div>
1629
- </div>
1630
- </div>
1631
- </td>
1632
-
1633
- <!-- Life assured -->
1634
- <td width="50%">
1635
- <div class="flex flex-col justify-between min-h-[250px] text-left">
1636
- <div>
1637
- <p style="margin:0;">
1638
- ហត្ថលេខា ឬស្នាមមេដៃរបស់អ្នកត្រូវបានធានារ៉ាប់រង
1639
- (ហត្ថលេខារបស់ឪពុកម្តាយ ឬអាណាព្យាបាលស្របច្បាប់ ប្រសិនបើអ្នក
1640
- ត្រូវបានធានារ៉ាប់រងមានអាយុក្រោម ១៨ ឆ្នាំ)
1641
- </p>
1642
- <p style="margin:0;">
1643
- Signature or thumb print of Life assured (Parent or the legal guardian's signature if the
1644
- Life assured is less than 18
1645
- years old)
1646
- </p>
1647
- </div>
1648
- <div class="flex items-center gap-2 w-full">
1649
- <span>ហត្ថលេខា ឬស្នាមមេដៃ / Signature or thumb print</span>
1650
-
1651
- <div class="flex-1 border-b border-black min-h-[18px] mt-1"></div>
1652
- </div>
1653
- </div>
1654
- </td>
1655
- </tr>
1656
- <!-- Names -->
1657
- <tr>
1658
- <td style="text-align: start; padding-top: 10px;">
1659
- <span>ឈ្មោះ</span>
1660
- <span>/ Name:</span>
1661
- <span style="font-weight: bold;">
1662
- <%= signature_info.ph_full_name %>
1663
- </span>
1664
- <!-- <span style="text-transform: uppercase; font-weight: bold;">SOK CHANTHA</span> -->
1665
- </td>
1666
- <td style="text-align: start; padding-top: 10px;">
1667
- <span>ឈ្មោះ</span>
1668
- <span>/ Name:</span>
1669
- <span style="font-weight: bold;">
1670
- <%= signature_info.la_full_name %>
1671
- </span>
1672
- <!-- <span style="font-weight: bold;">PHAN DARA</span> -->
1673
- </td>
1674
- </tr>
1675
- <!-- Dates -->
1676
- <tr>
1677
- <td style="text-align: start; padding-top: 10px;">
1678
- <span>កាលបរិច្ឆេទ</span>
1679
- <span>
1680
- Date:
1681
- <%- signature_info.ph_signature_date ? '<u><b>' + signature_info.ph_signature_date + '</b></u>'
1682
- : '<span style="display:inline-block; width:120px; border-bottom:1px solid #000; min-height:18px;"></span>'
1683
- %>
1684
- </span>
1685
- </td>
1686
- <td style="text-align: start; padding-top: 10px;">
1687
- <span>កាលបរិច្ឆេទ</span>
1688
- <span>
1689
- Date:
1690
- <%- signature_info.la_signature_date ? '<u><b>' + signature_info.la_signature_date + '</b></u>'
1691
- : '<span style="display:inline-block; width:120px; border-bottom:1px solid #000; min-height:18px;"></span>'
1692
- %>
1693
- </span>
1694
- </td>
1695
- </tr>
1696
- </tbody>
1697
- </table>
1698
- </div>
1699
-
1700
- <div class="question-row declaration-header">
1701
- <table class="form-table w-full table-fixed mt-2" cellpadding="15">
1702
- <!-- Signature line -->
1703
- <tr>
1704
- <td style="height: 50px; vertical-align: center; text-align: start;">
1705
- <p>
1706
- <span>
1707
- ហត្ថលេខា ឬស្នាមមេដៃរបស់ទីប្រឹក្សាធានារ៉ាប់រង ឬសាក្សី
1708
- </span>
1709
- <span>
1710
- (Signature or thumb print of Advisor/witness)
1711
- </span>
1712
- <br>
1713
- <div class="flex-1 border-b border-black min-h-[50px] mt-1"></div>
1714
- </p>
1715
- </td>
1716
- </tr>
1717
- <!-- Name -->
1718
- <tr>
1719
- <td style="text-align: start; vertical-align: center; padding-top: 5px;">
1720
- <span>ឈ្មោះ</span>
1721
- <span>
1722
- Name:
1723
- <%- signature_info.agent_full_name ? '<u><b>' + signature_info.agent_full_name+ '</b></u>'
1724
- : '<span style="display:inline-block; width:120px; border-bottom:1px solid #000; min-height:18px;"></span>'
1725
- %>
1726
- </span>
1727
- </td>
1728
- </tr>
1729
- <!-- Date -->
1730
- <tr>
1731
- <td style="text-align: start; vertical-align: center; padding-top: 5px;">
1732
- <span>កាលបរិច្ឆេទ</span>
1733
- <span>
1734
- Date:
1735
- <%- signature_info.agent_signature_date ? '<u><b>' + signature_info.agent_signature_date+ '</b></u>'
1736
- : '<span style="display:inline-block; width:120px; border-bottom:1px solid #000; min-height:18px;"></span>'
1737
- %>
1738
- </span>
1739
- </td>
1740
- </tr>
1741
- </table>
1742
- </div>
1743
-
1744
- <div class="question-row declaration-header">
1745
- <table style="margin-top: 10px;" class="width-100 form-table" cellpadding="15">
1746
- <tbody class="width-100">
1747
- <!-- Title -->
1748
- <tr class="width-100" cellpadding="10">
1749
- <td colspan="3" style="text-align:center;" class="text-lg font-bold">
1750
- <h5>ការបញ្ជាក់ដោយអ្នកតំណាង ហ្វីលីព ឡាយហ្វ៍ អាសួរេន (ខេមបូឌា) ម.ក</h5>
1751
- <h5>Phillip Life Assurance (Cambodia) Plc Representative Certification</h5>
1752
- </td>
1753
- </tr>
1754
- <!-- Content -->
1755
- <tr>
1756
- <td style="text-align: start;">
1757
- <p>
1758
- ខ្ញុំបានជួបអ្នកដាក់ពាក្យស្នើសុំ និងអ្នកដែលនឹងត្រូវបានធានារ៉ាប់រងដោយផ្ទាល់
1759
- និងបានពន្យល់អំពី ខ និងលក្ខខណ្ឌនៃបណ្ណសន្យារ៉ាប់រងដល់អ្នកដាក់ពាក្យស្នើសុំ។
1632
+ <div>
1633
+ <p style="margin:0;">
1634
+ ហត្ថលេខា ឬស្នាមមេដៃរបស់ម្ចាស់បណ្ណសន្យារ៉ាប់រង
1760
1635
  </p>
1761
-
1762
- <p>
1763
- ខ្ញុំបានឃើញអត្តសញ្ញាណប័ណ្ណរបស់អ្នកដាក់ពាក្យស្នើសុំ និងបានថតចំលងត្រឹមត្រូវតាមច្បាប់ដើម។
1764
- ខ្ញុំសូមបញ្ជាក់ថាលេខអត្តសញ្ញាណប័ណ្ណរបស់អ្នកដាក់ពាក្យស្នើសុំគឺ
1765
- <u><b>
1766
- <%= rep_certification_info.identifier_no %>
1767
- </b></u>
1768
- និងមានថ្ងៃខែឆ្នាំកំណើត
1769
- <u><b>
1770
- <%= rep_certification_info.date_of_birth %>
1771
- </b></u>
1772
- ពិតជារបស់អ្នកដាក់ពាក្យស្នើសុំពិតប្រាកដមែន។
1636
+ <p style="margin:0;">
1637
+ Signature or thumb print of Policyholder
1773
1638
  </p>
1774
- <br>
1775
- <p class="text-justify">
1776
- I have personally seen the Applicant and the Life Assured and have explained the terms and
1777
- conditions of the policy to
1778
- the Applicant.
1779
- I have seen the ID of the Applicant and original copy. I certify that the date of birth and ID
1780
- number truly belong to
1781
- the Applicant.
1639
+ </div>
1640
+ <div class="flex items-center gap-2 w-full">
1641
+ <span>ហត្ថលេខា ឬស្នាមមេដៃ / Signature or thumb print</span>
1642
+
1643
+ <div class="flex-1 border-b border-black min-h-[18px] mt-1"></div>
1644
+ </div>
1645
+ </div>
1646
+ </td>
1647
+
1648
+ <!-- Life assured -->
1649
+ <td width="50%">
1650
+ <div class="flex flex-col justify-between min-h-[250px] text-left">
1651
+ <div>
1652
+ <p style="margin:0;">
1653
+ ហត្ថលេខា ឬស្នាមមេដៃរបស់អ្នកត្រូវបានធានារ៉ាប់រង
1654
+ (ហត្ថលេខារបស់ឪពុកម្តាយ ឬអាណាព្យាបាលស្របច្បាប់ ប្រសិនបើអ្នក
1655
+ ត្រូវបានធានារ៉ាប់រងមានអាយុក្រោម ១៨ ឆ្នាំ)
1782
1656
  </p>
1783
- <br><br><br><br>
1784
-
1785
- <!-- Signature -->
1786
- <p>
1787
- <span>ហត្ថលេខា និងឈ្មោះ</span>
1788
- <span> / Signature and name: </span>
1789
- <u>
1790
- <span style="text-transform: uppercase; font-weight: bold">
1791
- <%= rep_certification_info.rep_full_name %>
1792
- </span>
1793
- </u>
1657
+ <p style="margin:0;">
1658
+ Signature or thumb print of Life assured (Parent or the legal guardian's signature if the
1659
+ Life assured is less than 18
1660
+ years old)
1794
1661
  </p>
1795
- </td>
1796
- </tr>
1797
- </tbody>
1798
- </table>
1799
- </div>
1800
-
1801
- <div class="question-row declaration-header">
1802
- <table style="margin-top: 10px; width: 100%; table-layout: fixed;" class="form-table" cellpadding="15">
1803
- <tbody>
1804
- <!-- Header -->
1805
- <tr>
1806
- <td colspan="3" style="text-align: center;" class="text-lg font-bold">
1807
- <h5>ហ្វីលីព ឡាយហ្វ៍ អាសួរេន (ខេមបូឌា) ម.ក</h5>
1808
- <h5>Phillip Life Assurance (Cambodia) Plc</h5>
1809
- </td>
1810
- </tr>
1811
- <!-- Content -->
1812
- <tr>
1813
- <td style="text-align: left;" colspan="3">
1814
- <div>
1815
- <span>សម្រាប់ប្រើក្នុងក្រុមហ៊ុនតែប៉ុណ្ណោះ</span>
1816
- <span>/ For office Use Only:</span>
1817
-
1818
- <p style="text-align: left;">
1819
- <span>លេខពាក្យស្នើសុំធានារ៉ាប់រង</span>
1820
- <span>/ Application Number:</span>
1821
- <span style="font-weight: bold">
1822
- <%= agent_source_info.application_no %>
1823
- </span>
1824
- </p>
1825
- <p style="text-align: left;">
1826
- <span>លេខសម្គាល់អតិថិជន</span>
1827
- <span>/ Client Number:</span>
1828
- <span style="font-weight: bold">
1829
- <%= agent_source_info.client_no %>
1830
- </span>
1831
- </p>
1832
- <p style="text-align: left;">
1833
- <span>លេខបណ្ណសន្យារ៉ាប់រង</span>
1834
- <span>/ Policy Number:</span>
1835
- <span style="font-weight: bold">
1836
- <%= agent_source_info.policy_no %>
1837
- </span>
1838
- </p>
1839
- <p style="text-align: left;">
1840
- <span>លេខសម្គាល់ប្រភព</span>
1841
- <span>/ Source Code:</span>
1842
- <span style="font-weight: bold">
1843
- <%= agent_source_info.source_code %>
1844
- </span>
1845
- </p>
1846
- <p style="text-align: left;">
1847
- <span>លេខសម្គាល់អ្នកប្រឹក្សាធានារ៉ាប់រង</span>
1848
- <span>/ Insurance Advisor Code:</span>
1849
- <span style="font-weight: bold">
1850
- <%= agent_source_info.advisor_code %>
1851
- </span>
1852
- </p>
1853
- <p style="text-align: left;">
1854
- <span>លេខទូរស័ព្ទអ្នកប្រឹក្សាធានារ៉ាប់រង</span>
1855
- <span>/ Insurance Advisor Contact Number:</span>
1856
- <span style="font-weight: bold">
1857
- <%= agent_source_info.advisor_contact %>
1858
- </span>
1859
- </p>
1860
- </div>
1861
- </td>
1862
- </tr>
1863
-
1864
- </tbody>
1865
- </table>
1866
- <div class="mt-5 space-y-2">
1867
- <p>ព័ត៌មានលម្អិតបន្ថែម:
1868
- សូមប្រើប្រាស់កន្លែងខាងក្រោមដើម្បីឆ្លើយនឹងសំណួរប្រសិនបើទំហំនៅក្នុងកម្រងសំណួរខាងលើមិនគ្រប់គ្រាន់។</p>
1869
- <p>Additional Details: Please use the space bellow if there are insufficient space in the
1870
- questionnaire to provide your answers.</p>
1871
- </div>
1872
- </div>
1873
-
1874
-
1875
- </div>
1876
- </div>
1877
- </div>
1878
- </body>
1662
+ </div>
1663
+ <div class="flex items-center gap-2 w-full">
1664
+ <span>ហត្ថលេខា ឬស្នាមមេដៃ / Signature or thumb print</span>
1665
+
1666
+ <div class="flex-1 border-b border-black min-h-[18px] mt-1"></div>
1667
+ </div>
1668
+ </div>
1669
+ </td>
1670
+ </tr>
1671
+ <!-- Names -->
1672
+ <tr>
1673
+ <td style="text-align: start; padding-top: 10px;">
1674
+ <span>ឈ្មោះ</span>
1675
+ <span>/ Name:</span>
1676
+ <span style="font-weight: bold;">
1677
+ <%= signature_info.ph_full_name %>
1678
+ </span>
1679
+ <!-- <span style="text-transform: uppercase; font-weight: bold;">SOK CHANTHA</span> -->
1680
+ </td>
1681
+ <td style="text-align: start; padding-top: 10px;">
1682
+ <span>ឈ្មោះ</span>
1683
+ <span>/ Name:</span>
1684
+ <span style="font-weight: bold;">
1685
+ <%= signature_info.la_full_name %>
1686
+ </span>
1687
+ <!-- <span style="font-weight: bold;">PHAN DARA</span> -->
1688
+ </td>
1689
+ </tr>
1690
+ <!-- Dates -->
1691
+ <tr>
1692
+ <td style="text-align: start; padding-top: 10px;">
1693
+ <span>កាលបរិច្ឆេទ</span>
1694
+ <span>
1695
+ Date:
1696
+ <%- signature_info.ph_signature_date ? '<u><b>' + signature_info.ph_signature_date
1697
+ + '</b></u>'
1698
+ : '<span style="display:inline-block; width:120px; border-bottom:1px solid #000; min-height:18px;"></span>'
1699
+ %>
1700
+ </span>
1701
+ </td>
1702
+ <td style="text-align: start; padding-top: 10px;">
1703
+ <span>កាលបរិច្ឆេទ</span>
1704
+ <span>
1705
+ Date:
1706
+ <%- signature_info.la_signature_date ? '<u><b>' + signature_info.la_signature_date
1707
+ + '</b></u>'
1708
+ : '<span style="display:inline-block; width:120px; border-bottom:1px solid #000; min-height:18px;"></span>'
1709
+ %>
1710
+ </span>
1711
+ </td>
1712
+ </tr>
1713
+ </tbody>
1714
+ </table>
1715
+ </div>
1716
+
1717
+ <div class="question-row declaration-header">
1718
+ <table class="form-table w-full table-fixed mt-2" cellpadding="15">
1719
+ <!-- Signature line -->
1720
+ <tr>
1721
+ <td style="height: 50px; vertical-align: center; text-align: start;">
1722
+ <p>
1723
+ <span>
1724
+ ហត្ថលេខា ឬស្នាមមេដៃរបស់ទីប្រឹក្សាធានារ៉ាប់រង ឬសាក្សី
1725
+ </span>
1726
+ <span>
1727
+ (Signature or thumb print of Advisor/witness)
1728
+ </span>
1729
+ <br>
1730
+ <div class="flex-1 border-b border-black min-h-[50px] mt-1"></div>
1731
+ </p>
1732
+ </td>
1733
+ </tr>
1734
+ <!-- Name -->
1735
+ <tr>
1736
+ <td style="text-align: start; vertical-align: center; padding-top: 5px;">
1737
+ <span>ឈ្មោះ</span>
1738
+ <span>
1739
+ Name:
1740
+ <%- signature_info.agent_full_name ? '<u><b>' + signature_info.agent_full_name+ '</b></u>'
1741
+ : '<span style="display:inline-block; width:120px; border-bottom:1px solid #000; min-height:18px;"></span>'
1742
+ %>
1743
+ </span>
1744
+ </td>
1745
+ </tr>
1746
+ <!-- Date -->
1747
+ <tr>
1748
+ <td style="text-align: start; vertical-align: center; padding-top: 5px;">
1749
+ <span>កាលបរិច្ឆេទ</span>
1750
+ <span>
1751
+ Date:
1752
+ <%- signature_info.agent_signature_date ? '<u><b>' +
1753
+ signature_info.agent_signature_date+ '</b></u>'
1754
+ : '<span style="display:inline-block; width:120px; border-bottom:1px solid #000; min-height:18px;"></span>'
1755
+ %>
1756
+ </span>
1757
+ </td>
1758
+ </tr>
1759
+ </table>
1760
+ </div>
1761
+
1762
+ <div class="question-row declaration-header">
1763
+ <table style="margin-top: 10px;" class="width-100 form-table" cellpadding="15">
1764
+ <tbody class="width-100">
1765
+ <!-- Title -->
1766
+ <tr class="width-100" cellpadding="10">
1767
+ <td colspan="3" style="text-align:center;" class="text-lg font-bold">
1768
+ <h5>ការបញ្ជាក់ដោយអ្នកតំណាង ហ្វីលីព ឡាយហ្វ៍ អាសួរេន (ខេមបូឌា) ម.ក</h5>
1769
+ <h5>Phillip Life Assurance (Cambodia) Plc Representative Certification</h5>
1770
+ </td>
1771
+ </tr>
1772
+ <!-- Content -->
1773
+ <tr>
1774
+ <td style="text-align: start;">
1775
+ <p>
1776
+ ខ្ញុំបានជួបអ្នកដាក់ពាក្យស្នើសុំ និងអ្នកដែលនឹងត្រូវបានធានារ៉ាប់រងដោយផ្ទាល់
1777
+ និងបានពន្យល់អំពី ខ និងលក្ខខណ្ឌនៃបណ្ណសន្យារ៉ាប់រងដល់អ្នកដាក់ពាក្យស្នើសុំ។
1778
+ </p>
1779
+
1780
+ <p>
1781
+ ខ្ញុំបានឃើញអត្តសញ្ញាណប័ណ្ណរបស់អ្នកដាក់ពាក្យស្នើសុំ និងបានថតចំលងត្រឹមត្រូវតាមច្បាប់ដើម។
1782
+ ខ្ញុំសូមបញ្ជាក់ថាលេខអត្តសញ្ញាណប័ណ្ណរបស់អ្នកដាក់ពាក្យស្នើសុំគឺ
1783
+ <u><b>
1784
+ <%= rep_certification_info.identifier_no %>
1785
+ </b></u>
1786
+ និងមានថ្ងៃខែឆ្នាំកំណើត
1787
+ <u><b>
1788
+ <%= rep_certification_info.date_of_birth %>
1789
+ </b></u>
1790
+ ពិតជារបស់អ្នកដាក់ពាក្យស្នើសុំពិតប្រាកដមែន។
1791
+ </p>
1792
+ <br>
1793
+ <p class="text-justify">
1794
+ I have personally seen the Applicant and the Life Assured and have explained the terms and
1795
+ conditions of the policy to
1796
+ the Applicant.
1797
+ I have seen the ID of the Applicant and original copy. I certify that the date of birth and ID
1798
+ number truly belong to
1799
+ the Applicant.
1800
+ </p>
1801
+ <br><br><br><br>
1802
+
1803
+ <!-- Signature -->
1804
+ <p>
1805
+ <span>ហត្ថលេខា និងឈ្មោះ</span>
1806
+ <span> / Signature and name: </span>
1807
+ <u>
1808
+ <span style="text-transform: uppercase; font-weight: bold">
1809
+ <%= rep_certification_info.rep_full_name %>
1810
+ </span>
1811
+ </u>
1812
+ </p>
1813
+ </td>
1814
+ </tr>
1815
+ </tbody>
1816
+ </table>
1817
+ </div>
1818
+
1819
+ <div class="question-row declaration-header">
1820
+ <table style="margin-top: 10px; width: 100%; table-layout: fixed;" class="form-table" cellpadding="15">
1821
+ <tbody>
1822
+ <!-- Header -->
1823
+ <tr>
1824
+ <td colspan="3" style="text-align: center;" class="text-lg font-bold">
1825
+ <h5>ហ្វីលីព ឡាយហ្វ៍ អាសួរេន (ខេមបូឌា) ម.ក</h5>
1826
+ <h5>Phillip Life Assurance (Cambodia) Plc</h5>
1827
+ </td>
1828
+ </tr>
1829
+ <!-- Content -->
1830
+ <tr>
1831
+ <td style="text-align: left;" colspan="3">
1832
+ <div>
1833
+ <span>សម្រាប់ប្រើក្នុងក្រុមហ៊ុនតែប៉ុណ្ណោះ</span>
1834
+ <span>/ For office Use Only:</span>
1835
+
1836
+ <p style="text-align: left;">
1837
+ <span>លេខពាក្យស្នើសុំធានារ៉ាប់រង</span>
1838
+ <span>/ Application Number:</span>
1839
+ <span style="font-weight: bold">
1840
+ <%= agent_source_info.application_no %>
1841
+ </span>
1842
+ </p>
1843
+ <p style="text-align: left;">
1844
+ <span>លេខសម្គាល់អតិថិជន</span>
1845
+ <span>/ Client Number:</span>
1846
+ <span style="font-weight: bold">
1847
+ <%= agent_source_info.client_no %>
1848
+ </span>
1849
+ </p>
1850
+ <p style="text-align: left;">
1851
+ <span>លេខបណ្ណសន្យារ៉ាប់រង</span>
1852
+ <span>/ Policy Number:</span>
1853
+ <span style="font-weight: bold">
1854
+ <%= agent_source_info.policy_no %>
1855
+ </span>
1856
+ </p>
1857
+ <p style="text-align: left;">
1858
+ <span>លេខសម្គាល់ប្រភព</span>
1859
+ <span>/ Source Code:</span>
1860
+ <span style="font-weight: bold">
1861
+ <%= agent_source_info.source_code %>
1862
+ </span>
1863
+ </p>
1864
+ <p style="text-align: left;">
1865
+ <span>លេខសម្គាល់អ្នកប្រឹក្សាធានារ៉ាប់រង</span>
1866
+ <span>/ Insurance Advisor Code:</span>
1867
+ <span style="font-weight: bold">
1868
+ <%= agent_source_info.advisor_code %>
1869
+ </span>
1870
+ </p>
1871
+ <p style="text-align: left;">
1872
+ <span>លេខទូរស័ព្ទអ្នកប្រឹក្សាធានារ៉ាប់រង</span>
1873
+ <span>/ Insurance Advisor Contact Number:</span>
1874
+ <span style="font-weight: bold">
1875
+ <%= agent_source_info.advisor_contact %>
1876
+ </span>
1877
+ </p>
1878
+ </div>
1879
+ </td>
1880
+ </tr>
1881
+
1882
+ </tbody>
1883
+ </table>
1884
+ <div class="mt-5 space-y-2">
1885
+ <p>ព័ត៌មានលម្អិតបន្ថែម:
1886
+ សូមប្រើប្រាស់កន្លែងខាងក្រោមដើម្បីឆ្លើយនឹងសំណួរប្រសិនបើទំហំនៅក្នុងកម្រងសំណួរខាងលើមិនគ្រប់គ្រាន់។</p>
1887
+ <p>Additional Details: Please use the space bellow if there are insufficient space in the
1888
+ questionnaire to provide your answers.</p>
1889
+ </div>
1890
+ </div>
1891
+
1892
+
1893
+ </div>
1894
+ </div>
1895
+ </div>
1896
+ </body>
1879
1897
 
1880
1898
  </html>
1881
1899
  `;