npm - plac-micro-common - Versions diffs - 1.3.97 → 1.3.98 - Mend

plac-micro-common 1.3.97 → 1.3.98

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package/dist/libs/pdf-form/templates/sio-form-en.template.d.ts CHANGED Viewed

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1	- export declare const SIO_FORM_EN_TEMPLATE = "\n<!doctype html>\n<html lang=\"en\">\n <head>\n <meta charset=\"UTF-8\" />\n <meta name=\"viewport\" content=\"width=device-width, initial-scale=1.0\" />\n <title>SIO Insurance Application Form</title>\n <link rel=\"preconnect\" href=\"https://fonts.googleapis.com\">\n <link rel=\"preconnect\" href=\"https://fonts.gstatic.com\" crossorigin>\n <link href=\"https://fonts.googleapis.com/css2?family=Hanuman:wght@100..900&family=Moul&display=swap\" rel=\"stylesheet\">\n <style>\n body {\n font-family: Arial, Helvetica, system-ui, sans-serif;\n font-size: 12px;\n line-height: 1.4;\n margin: 1rem;\n /* Reduced from 2rem /\n background: #fff;\n color: #000;\n }\n\n .font-kh {\n font-family: 'Hanuman', sans-serif !important;\n }\n\n .space {\n width: 8px;\n }\n\n / margin /\n .ml-4 {margin-left: 1rem; }\n .ml-8 {margin-left: 2rem; }\n\n .mr-4 {margin-right: 1rem; }\n .mr-8 {margin-right: 2rem; }\n\n .mt-4 {margin-top: 1rem; }\n .mt-8 {margin-top: 2rem; }\n\n .mb-4 {margin-bottom: 1rem; }\n .mb-8 {margin-bottom: 2rem; }\n\n / alignment /\n .align-left { justify-content: flex-start !important; text-align: left; padding-left: 16px; }\n .align-right { justify-content: flex-end !important; text-align: right; padding-right: 16px; }\n .align-center { justify-content: center !important; text-align: center; }\n\n .space-height {\n height: 60px;\n align-items: center;\n }\n\n .signature-space {\n height: 100px;\n margin-top: 10px;\n }\n\n / === Page header === /\n .page-header {\n margin-bottom: 0.5rem;\n page-break-inside: avoid;\n }\n\n .header-container {\n display: flex;\n flex-direction: column;\n align-items: center;\n }\n\n .title-logo {\n width: 125px;\n height: auto;\n }\n\n .title {\n font-weight: 700;\n font-size: 14px;\n line-height: 1;\n }\n\n .title-container {\n text-align: center;\n font-weight: 700;\n font-size: 14px;\n line-height: 1.4;\n margin: 0;\n }\n\n / === Card Header === /\n .card-header {\n background-color: #0d6efd;\n color: white;\n text-align: center;\n padding: 0.1rem 0;\n border-radius: 6px 6px 0 0;\n font-size: 13px;\n font-weight: bold;\n margin-bottom: 0.5rem;\n / Reduced /\n -webkit-print-color-adjust: exact;\n print-color-adjust: exact;\n }\n\n / === Form Text === /\n .form-container {\n display: flex;\n flex-wrap: wrap;\n margin: 0;\n padding: 0;\n gap: 0.5rem;\n }\n\n .form-item {\n display: flex;\n align-items: flex-start;\n flex-wrap: wrap;\n width: 100%;\n }\n\n .label,\n .question-label {\n word-wrap: break-word;\n white-space: normal;\n font-weight: 500;\n color: #444;\n }\n\n / Underline for blanks /\n .underline {\n border-bottom: 1px dashed #000;\n flex: 1;\n min-width: 60px;\n min-height: 1em;\n display: inline-flex;\n align-items: center;\n justify-content: center;\n text-align: center;\n word-break: break-word;\n white-space: normal;\n -webkit-box-decoration-break: clone;\n box-decoration-break: clone;\n align-self: flex-end;\n color: #000;\n }\n\n / size variants /\n .underline.xs { flex: none; width: 30px; min-width: unset; }\n .underline.sm { flex: none; width: 80px; min-width: unset; }\n .underline.md { flex: none; width: 180px; min-width: unset; }\n .underline.lg { flex: 2; }\n\n .underline.with-unit {\n flex: 1;\n min-width: 0;\n display: block;\n word-break: break-word;\n white-space: normal;\n border-bottom: none;\n line-height: 1.6em;\n text-align: left;\n padding-left: 4px;\n }\n\n .with-unit .value {\n display: inline;\n text-decoration: underline;\n text-decoration-style: dashed;\n text-decoration-color: #000; \n text-underline-offset: 3px; \n -webkit-box-decoration-break: clone;\n box-decoration-break: clone;\n vertical-align: baseline;\n }\n\n .unit {\n display: inline;\n white-space: nowrap;\n margin-left: 4px;\n text-decoration: none; \n }\n\n / Checkbox labels /\n .checkbox-label {\n display: inline-flex;\n align-items: center;\n gap: 0.5rem;\n position: relative;\n cursor: pointer;\n padding-left: 0.2rem;\n user-select: none;\n margin-right: 0.5rem;\n }\n\n .checkbox-label::before {\n content: \"\";\n display: inline-flex;\n align-items: center;\n justify-content: center;\n width: 20px;\n height: 20px;\n border: 2px solid #555;\n border-radius: 3px;\n background-color: #fff;\n box-sizing: border-box;\n flex-shrink: 0;\n }\n\n .checkbox-label.checked::after {\n content: \"\";\n position: absolute;\n top: 45%;\n left: calc(0.2rem + 7px);\n width: 6px;\n height: 12px;\n border: solid #0d6efd;\n border-width: 0 2px 2px 0;\n box-sizing: border-box;\n transform: translateY(-50%) rotate(45deg);\n pointer-events: none;\n }\n\n .page-break {\n page-break-before: always;\n }\n\n / === Table data === /\n .table-container {\n margin: auto;\n margin-bottom: 4px;\n }\n\n table {\n width: 100%;\n border-collapse: collapse;\n }\n\n th,\n td {\n border: 1px solid #ccc;\n padding: 0;\n }\n\n .cell {\n min-height: 10px;\n padding: 4px 8px;\n display: flex;\n justify-content: center;\n text-align: center;\n }\n\n th {\n font-weight: 600;\n }\n\n / === Print-specific: Footer with Page Numbers on the RIGHT === /\n @media print {\n body {\n margin: 0;\n padding-top: 10mm;\n }\n\n / Make room for footer on the right side /\n @page {\n size: A4 portrait;\n margin: 15mm 15mm 20mm 10mm;\n / increased right margin slightly for better spacing /\n\n @bottom-right {\n content: \"Page \" counter(page) \" of \" counter(pages);\n font-size: 11px;\n color: #555;\n }\n }\n\n / Increment page counter */\n body {\n counter-increment: page;\n }\n\n .page-header,\n .title-container,\n table {\n page-break-inside: avoid;\n }\n\n .card-header {\n -webkit-print-color-adjust: exact;\n print-color-adjust: exact;\n }\n }\n </style>\n </head>\n\n <body>\n <div class=\"page-header mb-8\">\n <img src=\"data:image/png;base64,<%= logo_base64 %>\" alt=\"Logo\" class=\"title-logo\" />\n <div class=\"title-container\">\n <h1 class=\"title\">LIFE ASSURANCE APPLICATION FORM</h1>\n <h1 class=\"title\">\n SIMPLIFY FORM FOR CHOKCHEY FINANCE PLC (SIO)\n </h1>\n </div>\n </div>\n\n <div class=\"form-container\">\n <div class=\"form-item\">\n <span class=\"label\">Branch Name and Code:</span>\n <span class=\"underline\">\n <%= branch_staff_app_info.branch_name %> / <%= branch_staff_app_info.branch_code %>\n </span>\n <span class=\"label\">Advisor's Name and Code:</span>\n <span class=\"underline\">\n <%= branch_staff_app_info.advisor_name %> / <%= branch_staff_app_info.advisor_code %>\n </span>\n </div>\n <div class=\"form-item\">\n <span class=\"label\">Bank staff's name and code:</span>\n <span class=\"underline\">\n <%= branch_staff_app_info.bank_staff_name %> / <%= branch_staff_app_info.bank_staff_code %>\n </span>\n <span class=\"label\">Application Number:</span>\n <span class=\"underline\">\n <%= branch_staff_app_info.application_no %>\n </span>\n </div>\n </div>\n\n <!-- Section 1 -->\n <div class=\"card-header mt-4\">INFORMATION ABOUT THE APPLICANT</div>\n\n <div class=\"form-container\">\n <div class=\"form-item\">\n <span class=\"label\">Full Name as shown in identity documents: in KH Language:</span>\n <span class=\"underline font-kh\"><%= applicant_info.full_name_kh %></span>\n <span class=\"label\">EN Language:</span>\n <span class=\"underline\"><%= applicant_info.full_name %></span>\n </div>\n\n <div class=\"form-item\">\n <span class=\"label\">Gender:</span>\n <label class=\"checkbox-label <%= applicant_info.gender === 'M' ? 'checked' : '' %>\">M</label>\n <label class=\"checkbox-label <%= applicant_info.gender === 'F' ? 'checked' : '' %>\">F</label>\n\n <div class=\"ml-8\"></div>\n\n <div>\n <span class=\"label\">Marital Status:</span>\n <label class=\"checkbox-label <%= applicant_info.marital_status === 'single' ? 'checked' : '' %>\">\n Single\n </label>\n <label class=\"checkbox-label <%= applicant_info.marital_status === 'married' ? 'checked' : '' %>\">\n Married\n </label>\n <label class=\"checkbox-label <%= applicant_info.marital_status === 'divorced' ? 'checked' : '' %>\">\n Divorced\n </label>\n <label class=\"checkbox-label <%= applicant_info.marital_status === 'widowed' ? 'checked' : '' %>\">\n Widowed\n </label>\n </div>\n </div>\n\n <div class=\"form-item\">\n <span class=\"label\">Job Title and Nature of Work:</span>\n <span class=\"underline align-left\"><%= applicant_info.occupation %></span>\n </div>\n\n <div class=\"form-item\">\n <span class=\"label\">Identity documents:</span>\n <label class=\"checkbox-label <%= applicant_info.identity_type === 'nid' ? 'checked' : '' %>\">\n National ID Card\n </label>\n <label class=\"checkbox-label <%= applicant_info.identity_type === 'passport' ? 'checked' : '' %>\">\n Passport\n </label>\n <label class=\"checkbox-label <%= applicant_info.identity_type === 'birth' ? 'checked' : '' %>\">\n Birth Certificate\n </label>\n <label class=\"checkbox-label <%= applicant_info.identity_type === 'other' ? 'checked' : '' %>\">\n Others :\n </label>\n\n\n <!-- other field stays separate since it has extra input -->\n <label class=\"underline\"><%= applicant_info.identity_other_description %></label>\n </div>\n\n <div class=\"form-item\">\n <span class=\"label\">Identity #</span>\n <span class=\"underline\"><%= applicant_info.identity_no %></span>\n <span class=\"label\">DOB:</span>\n <span class=\"underline\"><%= applicant_info.date_of_birth %></span>\n <span class=\"label\">Age:</span>\n <span class=\"underline xs\"><%= applicant_info.age %></span>\n <span class=\"label\">Nationality:</span>\n <span class=\"underline\"><%= applicant_info.nationality %></span>\n <span class=\"label\">Phone #:</span>\n <span class=\"underline\"><%= applicant_info.phone_number %></span>\n </div>\n\n <div class=\"form-item\">\n <span class=\"label\">Current Address:</span>\n <span class=\"underline align-left\"><%= applicant_info.current_address %></span>\n </div>\n\n\n </div>\n\n\n\n <div class=\"form-container\">\n <div class=\"form-item mt-4\">\n <span class=\"label\">Declaration on FATCA implementation</span>\n </div>\n <div class=\"form-item\">\n <span class=\"label\">\n The Policyholder is not USA citizen / USA resident for tax purpose or holding Green Card.\n </span>\n </div>\n <div class=\"form-item\">\n <label class=\"checkbox-label <%= fatca_info.is_fatca === false ? 'checked' : '' %>\">No</label>\n <label class=\"checkbox-label <%= fatca_info.is_fatca === true ? 'checked' : '' %>\">Yes</label>\n <span class=\"label\">US TIN #:</span>\n <span class=\"underline\"><%= fatca_info.us_tin_no %></span>\n <span class=\"label\">FATCA Exemption Code (If have):</span>\n <span class=\"underline\"><%= fatca_info.fatca_exempt_code %></span>\n </div>\n <div class=\"form-item\">\n <span class=\"label\">\n If any of the certifications I have provided are incorrect, I will submit a new document within 30 days, and I certify that I am not subject to U.S. withholding tax.\n </span>\n </div>\n </div>\n\n\n\n <!-- Section 2 -->\n <div class=\"card-header mt-4\">INFORMATION ABOUT THE PRODUCT\n </div>\n <div class=\"table-container\">\n <table>\n <thead>\n <tr>\n <th><div class=\"cell\">NAME OF PRODUCT AND TERMS</div></th>\n <th><div class=\"cell\">SUM ASSURED (USD)</div></th>\n <th><div class=\"cell\">MODE OF PAYMENT</div></th>\n <th>\n <div class=\"cell\">PREMIUM (USD)</div>\n </th>\n </tr>\n </thead>\n <tbody>\n <% product_payment_info?.products?.forEach(function(product) { %>\n <tr>\n <td><div class=\"cell\"><%= product.name %> <%= product.term %></div></td>\n <td><div class=\"cell\"><%= product.sum_assured %></div></td>\n <td><div class=\"cell\"><%= product.payment_mode %></div></td>\n <td><div class=\"cell\"><%= product.premium %></div></td>\n </tr>\n <% }) %>\n </tbody>\n </table>\n </div>\n <div class=\"form-container\">\n <div class=\"form-item\">\n <span class=\"question-label\">Method of payment:</span>\n <label class=\"checkbox-label <%= product_payment_info.payment_method === 'transfer_to_plac' ? 'checked' : '' %>\">\n Credit to Phillip Life Account\n </label>\n <label class=\"checkbox-label <%= product_payment_info.payment_method === 'other' ? 'checked' : '' %>\">\n Through Phillip Life's partner\n </label>\n </div>\n </div>\n\n <!-- Section 3 -->\n <div class=\"card-header mt-4\">INFORMATION ABOUT THE BENEFICIARY(IES)</div>\n <div class=\"table-container\">\n <table>\n <thead>\n <tr>\n <th><div class=\"cell\">FULL NAME OF BENEFICIARY</div></th>\n <th><div class=\"cell\">AGE</div></th>\n <th><div class=\"cell\">RELATIONSHIP</div></th>\n <th><div class=\"cell\">IDENTITY NUMBER</div></th>\n <th><div class=\"cell\">% OF SHARE</div></th>\n </tr>\n </thead>\n <tbody>\n <% beneficiary_info?.forEach(function(beneficiary) { %>\n <tr>\n <td><div class=\"cell\"><%= beneficiary.full_name %></div></td>\n <td><div class=\"cell\"><%= beneficiary.age %></div></td>\n <td><div class=\"cell\"><%= beneficiary.relationship %></div></td>\n <td><div class=\"cell\"><%= beneficiary.id_number %></div></td>\n <td><div class=\"cell\"><%= beneficiary.percentage %></div></td>\n </tr>\n <% }) %>\n <tr>\n <td colspan=\"4\">\n <div class=\"cell\">\n Note:\n If the percentage is not specified the amount will be shared equally\n </div>\n </td>\n <td><div class=\"cell\">% Total 100 %</div></td>\n </tr>\n </tbody>\n </table>\n </div>\n\n <!-- Section 4 -->\n <div class=\"page-break\"></div>\n <div class=\"card-header\">\n HEALTH RELATED QUESTIONS\n </div>\n\n <!-- Question 1 -->\n <div class=\"form-container\">\n <div class=\"form-item\">\n <span class=\"label\">1) Height:</span>\n <span class=\"underline sm\"><%= health_info.height %></span>\n <span class=\"label\">cm</span>\n <div class=\"space\"></div>\n <span class=\"label\">Weight:</span>\n <span class=\"underline sm\"><%= health_info.weight %></span>\n <span class=\"label\">Kg</span>\n <div class=\"space\"></div>\n <span class=\"question-label\">A) Do you smoke?</span>\n <label class=\"checkbox-label <%= health_info.is_smoke === false ? 'checked' : '' %>\">\n No\n </label>\n <label class=\"checkbox-label <%= health_info.is_smoke === true ? 'checked' : '' %>\">\n Yes\n </label>\n </div>\n\n <div class=\"form-item mb-4\">\n <span class=\"label\">How many</span>\n <% if (health_info.smoke_detail) { %>\n <span class=\"underline with-unit\">\n <span class=\"value\"><%= health_info.smoke_detail %></span>\n <span class=\"unit\">per day</span>\n </span>\n <% } else { %>\n <span class=\"underline\"></span>\n <% } %>\n </div>\n </div>\n\n <!-- Question 2 -->\n <div class=\"form-container\">\n <div class=\"form-item\">\n <span class=\"question-label\">2) Do you drink alcohol?</span>\n <label class=\"checkbox-label <%= health_info.is_drink_alcohol === false ? 'checked' : '' %>\">\n No\n </label>\n <label class=\"checkbox-label <%= health_info.is_drink_alcohol === true ? 'checked' : '' %>\">\n Yes\n </label>\n </div>\n <div class=\"form-item mb-4\">\n <span class=\"label\">Please specify amount of drink per week</span>\n <% if (health_info.drink_alcohol_detail) { %>\n <span class=\"underline with-unit\">\n <span class=\"value\"><%= health_info.drink_alcohol_detail %></span>\n </span>\n <% } else { %>\n <span class=\"underline\"></span>\n <% } %>\n </div>\n </div>\n\n <!-- Question 3 -->\n <div class=\"form-container\">\n <span class=\"question-label\">\n 3) In the past 2 years, have you ever been hospitalized, undergone any surgical operation, or had abnormal results such as: Blood test, Urine test, X-ray, ECG, Ultrasound, Scan, Biopsy or any other test results.\n </span>\n <div class=\"form-item\">\n <label class=\"checkbox-label <%= health_info.is_hospitalized === false ? 'checked' : '' %>\">\n No\n </label>\n <label class=\"checkbox-label <%= health_info.is_hospitalized === true ? 'checked' : '' %>\">\n Yes\n </label>\n </div>\n\n <div class=\"form-item mb-4\">\n <span class=\"label\">provided more details:</span>\n <% if (health_info.hospitalized_detail) { %>\n <span class=\"underline with-unit\">\n <span class=\"value\"><%= health_info.hospitalized_detail %></span>\n </span>\n <% } else { %>\n <span class=\"underline\"></span>\n <% } %>\n </div>\n </div>\n\n <!-- Question 4 -->\n <div class=\"form-container\"> \n <span class=\"question-label\">\n 4) Have you ever been diagnosed with, consulted a medical practitioner or been given treatment for any of the following conditions: Hypertension, Diabetes, Heart diseases, Chest pain, Lung diseases, Liver disease, Renal diseases, Cancer, Stroke, AIDS, Mental illness, Disability or Deformity, Drug or Alcohol Abuse or Any other diseases are not mentioned above.\n </span>\n <div class=\"form-item\">\n <label class=\"checkbox-label <%= health_info.is_diagnosed === false ? 'checked' : '' %>\">\n No\n </label>\n <label class=\"checkbox-label <%= health_info.is_diagnosed === true ? 'checked' : '' %>\">\n Yes\n </label>\n \n </div>\n <div class=\"form-item mb-4\">\n <span class=\"label\">if yes, please provided more details:</span>\n <% if (health_info.diagnosed_detail) { %>\n <span class=\"underline with-unit\">\n <span class=\"value\"><%= health_info.diagnosed_detail %></span>\n </span>\n <% } else { %>\n <span class=\"underline\"></span>\n <% } %>\n </div>\n </div>\n\n <!-- Section 5 -->\n <div class=\"card-header mt-4\">DECLARATION BY THE APPLICANT</div>\n <div class=\"form-container\">\n <div class=\"form-item\">\n <span class=\"label\">\n 1) I authorize and consent the Company to use all of my information provided in my application form for legal purposes such as marketing, market survey and customer service by company, affiliate, or business partner without my prior consent or notification. The Company shall not allow to disclose any information of any other purpose not related to the above-mentioned purpose without prior consent in writing.\n </span>\n </div>\n <div class=\"form-item\">\n <span class=\"label\">\n 2) I hereby confirm that I have read and understood all the information in this document. I declare that all the information provided in this application form is complete, accurate, and true.\n </span>\n </div>\n </div>\n <div class=\"table-container mt-4\">\n <table>\n <thead>\n <tr>\n <th style=\"width: 50%\">\n <div class=\"cell\">\n Signature or Thumb print of the Applicant\n </div>\n <div class=\"signature-space\"></div>\n </th>\n <th style=\"width: 50%\">\n <div class=\"cell\">Signature or Thumb print of the witness</div>\n <div class=\"signature-space\"></div>\n </th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td>\n <div class=\"form-container space-height\">\n <div class=\"form-item\">\n <div class=\"space\"></div>\n <span class=\"label\">Name</span>\n <% if (signature_info.applicant_name) { %>\n <span class=\"underline with-unit\">\n <span class=\"value\"><%= signature_info.applicant_name %></span>\n </span>\n <% } else { %>\n <span class=\"underline\"></span>\n <% } %>\n <div class=\"space\"></div> \n </div>\n </div>\n </td>\n <td>\n <div class=\"form-container space-height\">\n <div class=\"form-item\">\n <div class=\"space\"></div>\n <span class=\"label\">Name</span>\n <% if (signature_info.witness_name) { %>\n <span class=\"underline with-unit\">\n <span class=\"value\"><%= signature_info.witness_name %></span>\n </span>\n <% } else { %>\n <span class=\"underline\"></span>\n <% } %>\n <div class=\"space\"></div> \n </div>\n </div>\n </td>\n </tr>\n <tr>\n <td>\n <div class=\"form-container space-height\">\n <div class=\"form-item\">\n <div class=\"space\"></div>\n <span class=\"label\">Date</span>\n <% if (signature_info.applicant_signature_date) { %>\n <span class=\"underline with-unit\" >\n <span class=\"value\"><%= signature_info.applicant_signature_date %></span>\n </span>\n <% } else { %>\n <span class=\"underline\"></span>\n <% } %>\n <div class=\"space\"></div> \n </div>\n </div>\n </td>\n <td>\n <div class=\"form-container space-height\">\n <div class=\"form-item\">\n <div class=\"space\"></div>\n <span class=\"label\">Date</span>\n <% if (signature_info.witness_signature_date) { %>\n <span class=\"underline with-unit\">\n <span class=\"value\"><%= signature_info.witness_signature_date %></span>\n </span>\n <% } else { %>\n <span class=\"underline\"></span>\n <% } %>\n <div class=\"space\"></div> \n </div>\n </div>\n </td>\n </tr>\n </tbody>\n </table>\n </div>\n </body>\n</html>\n";
1	+ export declare const SIO_FORM_EN_TEMPLATE = "\n<!doctype html>\n<html lang=\"en\">\n\n<head>\n <meta charset=\"UTF-8\" />\n <meta name=\"viewport\" content=\"width=device-width, initial-scale=1.0\" />\n <title>SIO Insurance Application Form</title>\n <link rel=\"preconnect\" href=\"https://fonts.googleapis.com\">\n <link rel=\"preconnect\" href=\"https://fonts.gstatic.com\" crossorigin>\n <link href=\"https://fonts.googleapis.com/css2?family=Hanuman:wght@100..900&family=Moul&display=swap\" rel=\"stylesheet\">\n <style>\n body {\n font-family: Arial, Helvetica, system-ui, sans-serif;\n font-size: 12px;\n line-height: 1.4;\n margin: 1rem;\n /* Reduced from 2rem /\n background: #fff;\n color: #000;\n }\n\n .font-kh {\n font-family: 'Hanuman', sans-serif !important;\n }\n\n .space {\n width: 8px;\n }\n\n / margin /\n .ml-4 {\n margin-left: 1rem;\n }\n\n .ml-8 {\n margin-left: 2rem;\n }\n\n .mr-4 {\n margin-right: 1rem;\n }\n\n .mr-8 {\n margin-right: 2rem;\n }\n\n .mt-4 {\n margin-top: 1rem;\n }\n\n .mt-8 {\n margin-top: 2rem;\n }\n\n .mb-4 {\n margin-bottom: 1rem;\n }\n\n .mb-8 {\n margin-bottom: 2rem;\n }\n\n / alignment /\n .align-left {\n justify-content: flex-start !important;\n text-align: left;\n padding-left: 16px;\n }\n\n .align-right {\n justify-content: flex-end !important;\n text-align: right;\n padding-right: 16px;\n }\n\n .align-center {\n justify-content: center !important;\n text-align: center;\n }\n\n .space-height {\n height: 60px;\n align-items: center;\n }\n\n .signature-space {\n height: 100px;\n margin-top: 10px;\n }\n\n / === Page header === /\n .page-header {\n margin-bottom: 0.5rem;\n page-break-inside: avoid;\n }\n\n .header-container {\n display: flex;\n flex-direction: column;\n align-items: center;\n }\n\n .title-logo {\n width: 125px;\n height: auto;\n }\n\n .title {\n font-weight: 700;\n font-size: 14px;\n line-height: 1;\n }\n\n .title-container {\n text-align: center;\n font-weight: 700;\n font-size: 14px;\n line-height: 1.4;\n margin: 0;\n }\n\n / === Card Header === /\n .card-header {\n background-color: #0d6efd;\n color: white;\n text-align: center;\n padding: 0.1rem 0;\n border-radius: 6px 6px 0 0;\n font-size: 13px;\n font-weight: bold;\n margin-bottom: 0.5rem;\n / Reduced /\n -webkit-print-color-adjust: exact;\n print-color-adjust: exact;\n }\n\n / === Form Text === /\n .form-container {\n display: flex;\n flex-wrap: wrap;\n margin: 0;\n padding: 0;\n gap: 0.5rem;\n }\n\n .form-item {\n display: flex;\n align-items: flex-start;\n flex-wrap: wrap;\n width: 100%;\n }\n\n .label,\n .question-label {\n word-wrap: break-word;\n white-space: normal;\n font-weight: 500;\n color: #444;\n }\n\n / Underline for blanks /\n .underline {\n border-bottom: 1px dashed #000;\n flex: 1;\n min-width: 60px;\n min-height: 1em;\n display: inline-flex;\n align-items: center;\n justify-content: center;\n text-align: center;\n word-break: break-word;\n white-space: normal;\n -webkit-box-decoration-break: clone;\n box-decoration-break: clone;\n align-self: flex-end;\n color: #000;\n }\n\n / size variants /\n .underline.xs {\n flex: none;\n width: 30px;\n min-width: unset;\n }\n\n .underline.sm {\n flex: none;\n width: 80px;\n min-width: unset;\n }\n\n .underline.md {\n flex: none;\n width: 180px;\n min-width: unset;\n }\n\n .underline.lg {\n flex: 2;\n }\n\n .underline.with-unit {\n flex: 1;\n min-width: 0;\n display: block;\n word-break: break-word;\n white-space: normal;\n border-bottom: none;\n line-height: 1.6em;\n text-align: left;\n padding-left: 4px;\n }\n\n .with-unit .value {\n display: inline;\n text-decoration: underline;\n text-decoration-style: dashed;\n text-decoration-color: #000;\n text-underline-offset: 3px;\n -webkit-box-decoration-break: clone;\n box-decoration-break: clone;\n vertical-align: baseline;\n }\n\n .unit {\n display: inline;\n white-space: nowrap;\n margin-left: 4px;\n text-decoration: none;\n }\n\n / Checkbox labels /\n .checkbox-label {\n display: inline-flex;\n align-items: center;\n gap: 0.5rem;\n position: relative;\n cursor: pointer;\n padding-left: 0.2rem;\n user-select: none;\n margin-right: 0.5rem;\n }\n\n .checkbox-label::before {\n content: \"\";\n display: inline-flex;\n align-items: center;\n justify-content: center;\n width: 20px;\n height: 20px;\n border: 2px solid #555;\n border-radius: 3px;\n background-color: #fff;\n box-sizing: border-box;\n flex-shrink: 0;\n }\n\n .checkbox-label.checked::after {\n content: \"\";\n position: absolute;\n top: 45%;\n left: calc(0.2rem + 7px);\n width: 6px;\n height: 12px;\n border: solid #0d6efd;\n border-width: 0 2px 2px 0;\n box-sizing: border-box;\n transform: translateY(-50%) rotate(45deg);\n pointer-events: none;\n }\n\n .page-break {\n page-break-before: always;\n }\n\n / === Table data === /\n .table-container {\n margin: auto;\n margin-bottom: 4px;\n }\n\n table {\n width: 100%;\n border-collapse: collapse;\n }\n\n th,\n td {\n border: 1px solid #ccc;\n padding: 0;\n }\n\n .cell {\n min-height: 10px;\n padding: 4px 8px;\n display: flex;\n justify-content: center;\n text-align: center;\n }\n\n th {\n font-weight: 600;\n }\n\n / === Print-specific: Footer with Page Numbers on the RIGHT === /\n @media print {\n body {\n margin: 0;\n padding-top: 10mm;\n }\n\n / Make room for footer on the right side /\n @page {\n size: A4 portrait;\n margin: 15mm 15mm 20mm 10mm;\n / increased right margin slightly for better spacing /\n\n / @bottom-right {\n content: \"Page \" counter(page) \" of \" counter(pages);\n font-size: 11px;\n color: #555;\n } /\n }\n\n / Increment page counter */\n body {\n counter-increment: page;\n }\n\n .page-header,\n .title-container,\n table {\n page-break-inside: avoid;\n }\n\n .card-header {\n -webkit-print-color-adjust: exact;\n print-color-adjust: exact;\n }\n }\n </style>\n</head>\n\n<body>\n <div class=\"page-header mb-8\">\n <img src=\"data:image/png;base64,<%= logo_base64 %>\" alt=\"Logo\" class=\"title-logo\" />\n <div class=\"title-container\">\n <h1 class=\"title\">LIFE ASSURANCE APPLICATION FORM</h1>\n <h1 class=\"title\">\n SIMPLIFY FORM FOR CHOKCHEY FINANCE PLC (SIO)\n </h1>\n </div>\n </div>\n\n <div class=\"form-container\">\n <div class=\"form-item\">\n <span class=\"label\">Branch Name and Code:</span>\n <span class=\"underline\">\n <%= branch_staff_app_info.branch_name %> / <%= branch_staff_app_info.branch_code %>\n </span>\n <span class=\"label\">Advisor's Name and Code:</span>\n <span class=\"underline\">\n <%= branch_staff_app_info.advisor_name %> / <%= branch_staff_app_info.advisor_code %>\n </span>\n </div>\n <div class=\"form-item\">\n <span class=\"label\">Bank staff's name and code:</span>\n <span class=\"underline\">\n <%= branch_staff_app_info.bank_staff_name %> / <%= branch_staff_app_info.bank_staff_code %>\n </span>\n <span class=\"label\">Application Number:</span>\n <span class=\"underline\">\n <%= branch_staff_app_info.application_no %>\n </span>\n </div>\n </div>\n\n <!-- Section 1 -->\n <div class=\"card-header mt-4\">INFORMATION ABOUT THE APPLICANT</div>\n\n <div class=\"form-container\">\n <div class=\"form-item\">\n <span class=\"label\">Full Name as shown in identity documents: in KH Language:</span>\n <span class=\"underline font-kh\">\n <%= applicant_info.full_name_kh %>\n </span>\n <span class=\"label\">EN Language:</span>\n <span class=\"underline\">\n <%= applicant_info.full_name %>\n </span>\n </div>\n\n <div class=\"form-item\">\n <span class=\"label\">Gender:</span>\n <label class=\"checkbox-label <%= applicant_info.gender === 'M' ? 'checked' : '' %>\">M</label>\n <label class=\"checkbox-label <%= applicant_info.gender === 'F' ? 'checked' : '' %>\">F</label>\n\n <div class=\"ml-8\"></div>\n\n <div>\n <span class=\"label\">Marital Status:</span>\n <label class=\"checkbox-label <%= applicant_info.marital_status === 'single' ? 'checked' : '' %>\">\n Single\n </label>\n <label class=\"checkbox-label <%= applicant_info.marital_status === 'married' ? 'checked' : '' %>\">\n Married\n </label>\n <label class=\"checkbox-label <%= applicant_info.marital_status === 'divorced' ? 'checked' : '' %>\">\n Divorced\n </label>\n <label class=\"checkbox-label <%= applicant_info.marital_status === 'widowed' ? 'checked' : '' %>\">\n Widowed\n </label>\n </div>\n </div>\n\n <div class=\"form-item\">\n <span class=\"label\">Job Title and Nature of Work:</span>\n <span class=\"underline align-left\">\n <%= applicant_info.occupation %>\n </span>\n </div>\n\n <div class=\"form-item\">\n <span class=\"label\">Identity documents:</span>\n <label class=\"checkbox-label <%= applicant_info.identity_type === 'nid' ? 'checked' : '' %>\">\n National ID Card\n </label>\n <label class=\"checkbox-label <%= applicant_info.identity_type === 'passport' ? 'checked' : '' %>\">\n Passport\n </label>\n <label class=\"checkbox-label <%= applicant_info.identity_type === 'birth' ? 'checked' : '' %>\">\n Birth Certificate\n </label>\n <label class=\"checkbox-label <%= applicant_info.identity_type === 'other' ? 'checked' : '' %>\">\n Others :\n </label>\n\n\n <!-- other field stays separate since it has extra input -->\n <label class=\"underline\">\n <%= applicant_info.identity_other_description %>\n </label>\n </div>\n\n <div class=\"form-item\">\n <span class=\"label\">Identity #</span>\n <span class=\"underline\">\n <%= applicant_info.identity_no %>\n </span>\n <span class=\"label\">DOB:</span>\n <span class=\"underline\">\n <%= applicant_info.date_of_birth %>\n </span>\n <span class=\"label\">Age:</span>\n <span class=\"underline xs\">\n <%= applicant_info.age %>\n </span>\n <span class=\"label\">Nationality:</span>\n <span class=\"underline\">\n <%= applicant_info.nationality %>\n </span>\n <span class=\"label\">Phone #:</span>\n <span class=\"underline\">\n <%= applicant_info.phone_number %>\n </span>\n </div>\n\n <div class=\"form-item\">\n <span class=\"label\">Current Address:</span>\n <span class=\"underline align-left\">\n <%= applicant_info.current_address %>\n </span>\n </div>\n\n\n </div>\n\n\n\n <div class=\"form-container\">\n <div class=\"form-item mt-4\">\n <span class=\"label\">Declaration on FATCA implementation</span>\n </div>\n <div class=\"form-item\">\n <span class=\"label\">\n The Policyholder is USA citizen / USA resident for tax purpose or holding Green Card.\n </span>\n </div>\n <div class=\"form-item\">\n <label class=\"checkbox-label <%= fatca_info.is_fatca === false ? 'checked' : '' %>\">No</label>\n <label class=\"checkbox-label <%= fatca_info.is_fatca === true ? 'checked' : '' %>\">Yes</label>\n <span class=\"label\">US TIN #:</span>\n <span class=\"underline\">\n <%= fatca_info.us_tin_no %>\n </span>\n <span class=\"label\">FATCA Exemption Code (If have):</span>\n <span class=\"underline\">\n <%= fatca_info.fatca_exempt_code %>\n </span>\n </div>\n <div class=\"form-item\">\n <span class=\"label\">\n If any of the certifications I have provided are incorrect, I will submit a new document within 30 days, and I\n certify that I am not subject to U.S. withholding tax.\n </span>\n </div>\n </div>\n\n\n\n <!-- Section 2 -->\n <div class=\"card-header mt-4\">INFORMATION ABOUT THE PRODUCT\n </div>\n <div class=\"table-container\">\n <table>\n <thead>\n <tr>\n <th>\n <div class=\"cell\">NAME OF PRODUCT AND TERMS</div>\n </th>\n <th>\n <div class=\"cell\">SUM ASSURED (USD)</div>\n </th>\n <th>\n <div class=\"cell\">MODE OF PAYMENT</div>\n </th>\n <th>\n <div class=\"cell\">PREMIUM (USD)</div>\n </th>\n </tr>\n </thead>\n <tbody>\n <% product_payment_info?.products?.forEach(function(product) { %>\n <tr>\n <td>\n <div class=\"cell\">\n <%= product.name %>\n <%= product.term %>\n </div>\n </td>\n <td>\n <div class=\"cell\">\n <%= product.sum_assured %>\n </div>\n </td>\n <td>\n <div class=\"cell\">\n <%= product.payment_mode %>\n </div>\n </td>\n <td>\n <div class=\"cell\">\n <%= product.premium %>\n </div>\n </td>\n </tr>\n <% }) %>\n </tbody>\n </table>\n </div>\n <div class=\"form-container\">\n <div class=\"form-item\">\n <span class=\"question-label\">Method of payment:</span>\n <label class=\"checkbox-label <%= product_payment_info.payment_method === 'transfer_to_plac' ? 'checked' : '' %>\">\n Credit to Phillip Life Account\n </label>\n <label class=\"checkbox-label <%= product_payment_info.payment_method === 'other' ? 'checked' : '' %>\">\n Through Phillip Life's partner\n </label>\n </div>\n </div>\n\n <% if (loan_info) { %>\n <div class=\"card-header mt-4\">LOAN INFORMATION</div>\n <div class=\"table-container\">\n <table>\n <thead>\n <tr>\n <th>\n <div class=\"cell\">LOAN AMOUNT</div>\n </th>\n <th>\n <div class=\"cell\">LOAN TERM</div>\n </th>\n <th>\n <div class=\"cell\">LOAN TYPE</div>\n </th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td>\n <div class=\"cell\">\n <%= loan_info.loan_amount %>\n </div>\n </td>\n <td>\n <div class=\"cell\">\n <%= loan_info.loan_duration %>\n </div>\n </td>\n <td>\n <div class=\"cell\">\n <%= loan_info.loan_type %>\n </div>\n </td>\n </tr>\n </tbody>\n </table>\n </div>\n \n <% } %>\n\n <!-- Section 3 -->\n <div class=\"card-header mt-4\">INFORMATION ABOUT THE BENEFICIARY(IES)</div>\n <div class=\"table-container\">\n <table>\n <thead>\n <tr>\n <th>\n <div class=\"cell\">FULL NAME OF BENEFICIARY</div>\n </th>\n <th>\n <div class=\"cell\">AGE</div>\n </th>\n <th>\n <div class=\"cell\">RELATIONSHIP</div>\n </th>\n <th>\n <div class=\"cell\">IDENTITY NUMBER</div>\n </th>\n <th>\n <div class=\"cell\">SHARE</div>\n </th>\n </tr>\n </thead>\n <tbody>\n <% beneficiary_info?.forEach(function(beneficiary) { %>\n <tr>\n <td>\n <div class=\"align-left\">\n <%= beneficiary.full_name %>\n </div>\n </td>\n <td>\n <div class=\"cell\">\n <%= beneficiary.age %>\n </div>\n </td>\n <td>\n <div class=\"cell\">\n <%= beneficiary.relationship %>\n </div>\n </td>\n <td>\n <div class=\"cell\">\n <%= beneficiary.id_number %>\n </div>\n </td>\n <td>\n <div class=\"cell\">\n <%= beneficiary.percentage %>\n </div>\n </td>\n </tr>\n <% }) %>\n <tr>\n <td colspan=\"5\">\n <div class=\"cell align-left\"\n style=\"text-align: start !important; padding-top: 5px; padding-bottom: 5px;\">\n The company will pay benefits to the primary beneficiary first before paying any remaining benefits to\n the secondary beneficiary designated by the applicant or to the heirs of the insured if no beneficiary\n is appointed.\n </div>\n </td>\n </tr>\n </tbody>\n </table>\n </div>\n\n <!-- Section 4 -->\n <div class=\"page-break\"></div>\n <div class=\"card-header\">\n HEALTH RELATED QUESTIONS\n </div>\n\n <!-- Question 1 -->\n <div class=\"form-container\">\n <div class=\"form-item\">\n <span class=\"label\">1) Height:</span>\n <span class=\"underline sm\">\n <%= health_info.height %>\n </span>\n <span class=\"label\">cm</span>\n <div class=\"space\"></div>\n <span class=\"label\">Weight:</span>\n <span class=\"underline sm\">\n <%= health_info.weight %>\n </span>\n <span class=\"label\">Kg</span>\n <div class=\"space\"></div>\n <span class=\"question-label\">A) Do you smoke?</span>\n <label class=\"checkbox-label <%= health_info.is_smoke === false ? 'checked' : '' %>\">\n No\n </label>\n <label class=\"checkbox-label <%= health_info.is_smoke === true ? 'checked' : '' %>\">\n Yes\n </label>\n </div>\n\n <div class=\"form-item mb-4\">\n <span class=\"label\">How many</span>\n <% if (health_info.smoke_detail) { %>\n <span class=\"underline with-unit\">\n <span class=\"value\">\n <%= health_info.smoke_detail %>\n </span>\n <span class=\"unit\">per day</span>\n </span>\n <% } else { %>\n <span class=\"underline\"></span>\n <% } %>\n </div>\n </div>\n\n <!-- Question 2 -->\n <div class=\"form-container\">\n <div class=\"form-item\">\n <span class=\"question-label\">2) Do you drink alcohol?</span>\n <label class=\"checkbox-label <%= health_info.is_drink_alcohol === false ? 'checked' : '' %>\">\n No\n </label>\n <label class=\"checkbox-label <%= health_info.is_drink_alcohol === true ? 'checked' : '' %>\">\n Yes\n </label>\n </div>\n <div class=\"form-item mb-4\">\n <span class=\"label\">Please specify amount of drink per week</span>\n <% if (health_info.drink_alcohol_detail) { %>\n <span class=\"underline with-unit\">\n <span class=\"value\">\n <%= health_info.drink_alcohol_detail %>\n </span>\n </span>\n <% } else { %>\n <span class=\"underline\"></span>\n <% } %>\n </div>\n </div>\n\n <!-- Question 3 -->\n <div class=\"form-container\">\n <span class=\"question-label\">\n 3) In the past 2 years, have you ever been hospitalized, undergone any surgical operation, or had abnormal results\n such as: Blood test, Urine test, X-ray, ECG, Ultrasound, Scan, Biopsy or any other test results.\n </span>\n <div class=\"form-item\">\n <label class=\"checkbox-label <%= health_info.is_hospitalized === false ? 'checked' : '' %>\">\n No\n </label>\n <label class=\"checkbox-label <%= health_info.is_hospitalized === true ? 'checked' : '' %>\">\n Yes\n </label>\n </div>\n\n <div class=\"form-item mb-4\">\n <span class=\"label\">provided more details:</span>\n <% if (health_info.hospitalized_detail) { %>\n <span class=\"underline with-unit\">\n <span class=\"value\">\n <%= health_info.hospitalized_detail %>\n </span>\n </span>\n <% } else { %>\n <span class=\"underline\"></span>\n <% } %>\n </div>\n </div>\n\n <!-- Question 4 -->\n <div class=\"form-container\">\n <span class=\"question-label\">\n 4) Have you ever been diagnosed with, consulted a medical practitioner or been given treatment for any of the\n following conditions: Hypertension, Diabetes, Heart diseases, Chest pain, Lung diseases, Liver disease, Renal\n diseases, Cancer, Stroke, AIDS, Mental illness, Disability or Deformity, Drug or Alcohol Abuse or Any other\n diseases are not mentioned above.\n </span>\n <div class=\"form-item\">\n <label class=\"checkbox-label <%= health_info.is_diagnosed === false ? 'checked' : '' %>\">\n No\n </label>\n <label class=\"checkbox-label <%= health_info.is_diagnosed === true ? 'checked' : '' %>\">\n Yes\n </label>\n\n </div>\n <div class=\"form-item mb-4\">\n <span class=\"label\">if yes, please provided more details:</span>\n <% if (health_info.diagnosed_detail) { %>\n <span class=\"underline with-unit\">\n <span class=\"value\">\n <%= health_info.diagnosed_detail %>\n </span>\n </span>\n <% } else { %>\n <span class=\"underline\"></span>\n <% } %>\n </div>\n </div>\n\n <!-- Section 5 -->\n <div class=\"card-header mt-4\">DECLARATION BY THE APPLICANT</div>\n <div class=\"form-container\" style=\"margin: 15px 0px 15px 0px;\">\n <div class=\"form-item\">\n <ol style=\"padding-left: 1.2rem; margin: 0;\">\n <li class=\"label\" style=\"margin-bottom: 5px;\">\n I authorize and consent the Company to use all of my information provided in my application form for legal\n purposes such as marketing, market survey and customer service by company, affiliate, or business partner\n without my prior consent or notification. The Company shall not allow to disclose any information of any other\n purpose not related to the above-mentioned purpose without prior consent in writing.\n </li>\n <li class=\"label\">\n I hereby confirm that I have read and understood all the information in this document. I declare that all the\n information provided in this application form is complete, accurate, and true.\n </li>\n </ol>\n </div>\n </div>\n\n\n <div class=\"table-container mt-4\">\n <table>\n <thead>\n <tr>\n <th style=\"width: 50%\">\n <div class=\"cell\">\n Signature or Thumb print of the Applicant\n </div>\n <div class=\"signature-space\"></div>\n </th>\n <th style=\"width: 50%\">\n <div class=\"cell\">Signature or Thumb print of the witness</div>\n <div class=\"signature-space\"></div>\n </th>\n </tr>\n </thead>\n <tbody>\n <tr>\n <td>\n <div class=\"form-container space-height\">\n <div class=\"form-item\">\n <div class=\"space\"></div>\n <span class=\"label\">Name</span>\n <% if (signature_info.applicant_name) { %>\n <span class=\"underline with-unit\">\n <span class=\"value\">\n <%= signature_info.applicant_name %>\n </span>\n </span>\n <% } else { %>\n <span class=\"underline\"></span>\n <% } %>\n <div class=\"space\"></div>\n </div>\n </div>\n </td>\n <td>\n <div class=\"form-container space-height\">\n <div class=\"form-item\">\n <div class=\"space\"></div>\n <span class=\"label\">Name</span>\n <% if (signature_info.witness_name) { %>\n <span class=\"underline with-unit\">\n <span class=\"value\">\n <%= signature_info.witness_name %>\n </span>\n </span>\n <% } else { %>\n <span class=\"underline\"></span>\n <% } %>\n <div class=\"space\"></div>\n </div>\n </div>\n </td>\n </tr>\n <tr>\n <td>\n <div class=\"form-container space-height\">\n <div class=\"form-item\">\n <div class=\"space\"></div>\n <span class=\"label\">Date</span>\n <% if (signature_info.applicant_signature_date) { %>\n <span class=\"underline with-unit\">\n <span class=\"value\">\n <%= signature_info.applicant_signature_date %>\n </span>\n </span>\n <% } else { %>\n <span class=\"underline\"></span>\n <% } %>\n <div class=\"space\"></div>\n </div>\n </div>\n </td>\n <td>\n <div class=\"form-container space-height\">\n <div class=\"form-item\">\n <div class=\"space\"></div>\n <span class=\"label\">Date</span>\n <% if (signature_info.witness_signature_date) { %>\n <span class=\"underline with-unit\">\n <span class=\"value\">\n <%= signature_info.witness_signature_date %>\n </span>\n </span>\n <% } else { %>\n <span class=\"underline\"></span>\n <% } %>\n <div class=\"space\"></div>\n </div>\n </div>\n </td>\n </tr>\n </tbody>\n </table>\n </div>\n</body>\n\n</html>\n";