<link href="//maxcdn.bootstrapcdn.com/bootstrap/3.3.0/css/bootstrap.min.css" rel="stylesheet" id="bootstrap-css"> <script src="//maxcdn.bootstrapcdn.com/bootstrap/3.3.0/js/bootstrap.min.js"></script> <script src="//code.jquery.com/jquery-1.11.1.min.js"></script> <!------ Include the above in your HEAD tag ----------> <!-- Forked from www .j a va 2 s . c o m--> <link rel="stylesheet" type="text/css" href="http://netdna.bootstrapcdn.com/twitter-bootstrap/2.3.2/css/bootstrap-combined.min.css"> <div class="container"> <div class="accordion" id="searchAccordion"> <div class="accordion-group"> <div class="accordion-heading"> <a class="accordion-toggle" data-toggle="collapse" data-parent="#searchAccordion" href="#collapse1">TAB 1 – Contact Information</a> </div> <div id="collapse1" class="accordion-body collapse"> <div class="accordion-inner"> <form class="form-inline"> <div class="row"> <div class="col-md-4 col-sm-12"> <label>Member Company Name</label> <input id="contactco" class="input-large" type="text" /> </div> </div> <div class="row"> <div class="required-field-block col-md-4 col-sm-12"> <label>SBWC ID #</label> <input id="sbcwid" class="form-control" type="text"> <div class="required-icon"> <div class="text">*</div> </div> </div> <div class="col-md-4 col-sm-12"> <label>FEIN</label> <input id="fein" class="input-large" type="text" /> </div> </div> <div class="row"> <div class="col-md-6 col-sm-12"> <label>Contact Person</label> <input id="contactperson" class="input-large" type="text" /> </div> <div class="col-md-6 col-sm-12"> <label>Title</label> <input id="contacttitle" class="input-large" type="text" /> </div> </div> <div class="page-header"> <h3>Mailing Address </h3> </div> <div class="row"> <div class="col-md-12 col-sm-12"> <label>Mailing Address</label> <input id="membermailaddress" class="input-large" type="text" /> </div> </div> <div class="row"> <div class="col-md-4 col-sm-12"> <label>City</label> <input id="membermailcity" class="input-large" type="text" /> </div> <div class="col-md-4 col-sm-12"> <label>State</label> <input id="membermailstate" class="input-large" type="text" /> </div> <div class="col-md-4 col-sm-12"> <label>Zip</label> <input id="membermailzip" class="input-large" type="text" /> </div> </div> <div class="page-header"> <h3>Physical Address </h3> </div> <div class="row"> <div class="col-md-12 col-sm-12"> <label>Physical Address</label> <input id="memberphysaddress" class="input-large" type="text" /> </div> </div> <div class="row"> <div class="col-md-4 col-sm-12"> <label>City</label> <input id="memberphyscity" class="input-large" type="text" /> </div> <div class="col-md-4 col-sm-12"> <label>State</label> <input id="memberphysstate" class="input-large" type="text" /> </div> <div class="col-md-4 col-sm-12"> <label>Zip</label> <input id="memberphyszip" class="input-large" type="text" /> </div> </div> <div class="row"> <div class="col-md-4 col-sm-12"> <label>Telephone Number</label> <input id="membertelenumber" class="input-large" type="text" /> </div> <div class="col-md-4 col-sm-12"> <label>Facsimile Number</label> <input id="memberfax" class="input-large" type="text" /> </div> <div class="col-md-4 col-sm-12"> <label>Email Address</label> <input id="memberemail" class="input-large" type="text" /> </div> </div> </form> </div> </div> </div> <div class="accordion-group"> <div class="accordion-heading"> <a class="accordion-toggle" data-toggle="collapse" data-parent="#searchAccordion" href="#collapseTwo">TAB 2 – Claims Handling</a> </div> <div id="collapseTwo" class="accordion-body collapse"> <div class="accordion-inner"> <form class="form-inline"> <div class="row-fluid"> <div class="span4"> <label>Address</label> <input class="input-large" type="text" /> </div> <div class="span4"> <label>Assessor</label> <input class="input-medium typeahead" id="taAssessor" type="text" data-provide="typeahead" autocomplete="off" /> </div> <div class="span4"> <label>Client</label> <input class="input-large typeahead" id="taClient" type="text" data-provide="typeahead" autocomplete="off" /> </div> </div> <div class="row-fluid"> <div class="span4"> <label>Status</label> <input class="input-medium typeahead" id="taStatus" type="text" data-provide="typeahead" autocomplete="off" /> </div> <div class="span4"> <label>Type</label> <input class="input-large typeahead" id="taType" type="text" data-provide="typeahead" autocomplete="off" /> </div> <div class="span4"> <label>Department</label> <input class="input-medium typeahead" id="taDepartment" type="text" data-provide="typeahead" autocomplete="off" /> </div> </div> <div class="row-fluid"> <div class="span3"> <label>Client Ref</label> <input class="input-small" type="text" /> </div> <div class="span3"> <label>PO Number</label> <input class="input-small" type="text" /> </div> </div> </form> </div> </div> </div> <div class="accordion-group"> <div class="accordion-heading"> <a class="accordion-toggle" data-toggle="collapse" data-parent="#searchAccordion" href="#collapseOne">TAB 3– Parent Company</a> </div> <div id="collapseOne" class="accordion-body collapse in"> <div class="accordion-inner"> <form class="form-inline"> <div class="row-fluid"> <div class="span4"> <label>Postcode</label> <input class="input-medium" type="text" /> </div> <div class="span4"> <label>ID</label> <input class="input-medium" type="text" /> </div> <div class="span4"> <label>Region</label> <input class="input-medium typeahead" id="taRegion" type="text" data-provide="typeahead" autocomplete="off" /> </div> </div> <div class="row-fluid"> <div class="span3 offset1"> <label class="checkbox"> <input type="checkbox" />Include completed? </label> </div> <div class="span3"> <label class="checkbox"> <input type="checkbox" />Include cancelled? </label> </div> </div> </form> </div> </div> </div> <div class="accordion-group"> <div class="accordion-heading"> <a class="accordion-toggle" data-toggle="collapse" data-parent="#searchAccordion" href="#collapseTwo">TAB 4 – Additional Companies</a> </div> <div id="collapseTwo" class="accordion-body collapse"> <div class="accordion-inner"> <form class="form-inline"> <div class="row-fluid"> <div class="span4"> <label>Address</label> <input class="input-large" type="text" /> </div> <div class="span4"> <label>Assessor</label> <input class="input-medium typeahead" id="taAssessor" type="text" data-provide="typeahead" autocomplete="off" /> </div> <div class="span4"> <label>Client</label> <input class="input-large typeahead" id="taClient" type="text" data-provide="typeahead" autocomplete="off" /> </div> </div> <div class="row-fluid"> <div class="span4"> <label>Status</label> <input class="input-medium typeahead" id="taStatus" type="text" data-provide="typeahead" autocomplete="off" /> </div> <div class="span4"> <label>Type</label> <input class="input-large typeahead" id="taType" type="text" data-provide="typeahead" autocomplete="off" /> </div> <div class="span4"> <label>Department</label> <input class="input-medium typeahead" id="taDepartment" type="text" data-provide="typeahead" autocomplete="off" /> </div> </div> <div class="row-fluid"> <div class="span3"> <label>Client Ref</label> <input class="input-small" type="text" /> </div> <div class="span3"> <label>PO Number</label> <input class="input-small" type="text" /> </div> </div> </form> </div> </div> </div> <div class="accordion-group"> <div class="accordion-heading"> <a class="accordion-toggle" data-toggle="collapse" data-parent="#searchAccordion" href="#collapseTwo">TAB 5 – Change in Ownership</a> </div> <div id="collapseTwo" class="accordion-body collapse"> <div class="accordion-inner"> <form class="form-inline"> <div class="row-fluid"> <div class="span4"> <label>Address</label> <input class="input-large" type="text" /> </div> <div class="span4"> <label>Assessor</label> <input class="input-medium typeahead" id="taAssessor" type="text" data-provide="typeahead" autocomplete="off" /> </div> <div class="span4"> <label>Client</label> <input class="input-large typeahead" id="taClient" type="text" data-provide="typeahead" autocomplete="off" /> </div> </div> <div class="row-fluid"> <div class="span4"> <label>Status</label> <input class="input-medium typeahead" id="taStatus" type="text" data-provide="typeahead" autocomplete="off" /> </div> <div class="span4"> <label>Type</label> <input class="input-large typeahead" id="taType" type="text" data-provide="typeahead" autocomplete="off" /> </div> <div class="span4"> <label>Department</label> <input class="input-medium typeahead" id="taDepartment" type="text" data-provide="typeahead" autocomplete="off" /> </div> </div> <div class="row-fluid"> <div class="span3"> <label>Client Ref</label> <input class="input-small" type="text" /> </div> <div class="span3"> <label>PO Number</label> <input class="input-small" type="text" /> </div> </div> </form> </div> </div> </div> <div class="accordion-group"> <div class="accordion-heading"> <a class="accordion-toggle" data-toggle="collapse" data-parent="#searchAccordion" href="#collapseTwo">TAB 6 – Employee Data</a> </div> <div id="collapseTwo" class="accordion-body collapse"> <div class="accordion-inner"> <form class="form-inline"> <div class="row-fluid"> <div class="span4"> <label>Address</label> <input class="input-large" type="text" /> </div> <div class="span4"> <label>Assessor</label> <input class="input-medium typeahead" id="taAssessor" type="text" data-provide="typeahead" autocomplete="off" /> </div> <div class="span4"> <label>Client</label> <input class="input-large typeahead" id="taClient" type="text" data-provide="typeahead" autocomplete="off" /> </div> </div> <div class="row-fluid"> <div class="span4"> <label>Status</label> <input class="input-medium typeahead" id="taStatus" type="text" data-provide="typeahead" autocomplete="off" /> </div> <div class="span4"> <label>Type</label> <input class="input-large typeahead" id="taType" type="text" data-provide="typeahead" autocomplete="off" /> </div> <div class="span4"> <label>Department</label> <input class="input-medium typeahead" id="taDepartment" type="text" data-provide="typeahead" autocomplete="off" /> </div> </div> <div class="row-fluid"> <div class="span3"> <label>Client Ref</label> <input class="input-small" type="text" /> </div> <div class="span3"> <label>PO Number</label> <input class="input-small" type="text" /> </div> </div> </form> </div> </div> </div> <div class="accordion-group"> <div class="accordion-heading"> <a class="accordion-toggle" data-toggle="collapse" data-parent="#searchAccordion" href="#collapseTwo">TAB 7 – Claims Data</a> </div> <div id="collapseTwo" class="accordion-body collapse"> <div class="accordion-inner"> <form class="form-inline"> <div class="row-fluid"> <div class="span4"> <label>Address</label> <input class="input-large" type="text" /> </div> <div class="span4"> <label>Assessor</label> <input class="input-medium typeahead" id="taAssessor" type="text" data-provide="typeahead" autocomplete="off" /> </div> <div class="span4"> <label>Client</label> <input class="input-large typeahead" id="taClient" type="text" data-provide="typeahead" autocomplete="off" /> </div> </div> <div class="row-fluid"> <div class="span4"> <label>Status</label> <input class="input-medium typeahead" id="taStatus" type="text" data-provide="typeahead" autocomplete="off" /> </div> <div class="span4"> <label>Type</label> <input class="input-large typeahead" id="taType" type="text" data-provide="typeahead" autocomplete="off" /> </div> <div class="span4"> <label>Department</label> <input class="input-medium typeahead" id="taDepartment" type="text" data-provide="typeahead" autocomplete="off" /> </div> </div> <div class="row-fluid"> <div class="span3"> <label>Client Ref</label> <input class="input-small" type="text" /> </div> <div class="span3"> <label>PO Number</label> <input class="input-small" type="text" /> </div> </div> </form> </div> </div> </div> <div class="accordion-group"> <div class="accordion-heading"> <a class="accordion-toggle" data-toggle="collapse" data-parent="#searchAccordion" href="#collapseTwo">TAB 8 – Claims Data Continued</a> </div> <div id="collapseTwo" class="accordion-body collapse"> <div class="accordion-inner"> <form class="form-inline"> <div class="row-fluid"> <div class="span4"> <label>Address</label> <input class="input-large" type="text" /> </div> <div class="span4"> <label>Assessor</label> <input class="input-medium typeahead" id="taAssessor" type="text" data-provide="typeahead" autocomplete="off" /> </div> <div class="span4"> <label>Client</label> <input class="input-large typeahead" id="taClient" type="text" data-provide="typeahead" autocomplete="off" /> </div> </div> <div class="row-fluid"> <div class="span4"> <label>Status</label> <input class="input-medium typeahead" id="taStatus" type="text" data-provide="typeahead" autocomplete="off" /> </div> <div class="span4"> <label>Type</label> <input class="input-large typeahead" id="taType" type="text" data-provide="typeahead" autocomplete="off" /> </div> <div class="span4"> <label>Department</label> <input class="input-medium typeahead" id="taDepartment" type="text" data-provide="typeahead" autocomplete="off" /> </div> </div> <div class="row-fluid"> <div class="span3"> <label>Client Ref</label> <input class="input-small" type="text" /> </div> <div class="span3"> <label>PO Number</label> <input class="input-small" type="text" /> </div> </div> </form> </div> </div> </div> <div class="accordion-group"> <div class="accordion-heading"> <a class="accordion-toggle" data-toggle="collapse" data-parent="#searchAccordion" href="#collapseTwo">TAB 9 – Reimbursable Claims</a> </div> <div id="collapseTwo" class="accordion-body collapse"> <div class="accordion-inner"> <form class="form-inline"> <div class="row-fluid"> <div class="span4"> <label>Address</label> <input class="input-large" type="text" /> </div> <div class="span4"> <label>Assessor</label> <input class="input-medium typeahead" id="taAssessor" type="text" data-provide="typeahead" autocomplete="off" /> </div> <div class="span4"> <label>Client</label> <input class="input-large typeahead" id="taClient" type="text" data-provide="typeahead" autocomplete="off" /> </div> </div> <div class="row-fluid"> <div class="span4"> <label>Status</label> <input class="input-medium typeahead" id="taStatus" type="text" data-provide="typeahead" autocomplete="off" /> </div> <div class="span4"> <label>Type</label> <input class="input-large typeahead" id="taType" type="text" data-provide="typeahead" autocomplete="off" /> </div> <div class="span4"> <label>Department</label> <input class="input-medium typeahead" id="taDepartment" type="text" data-provide="typeahead" autocomplete="off" /> </div> </div> <div class="row-fluid"> <div class="span3"> <label>Client Ref</label> <input class="input-small" type="text" /> </div> <div class="span3"> <label>PO Number</label> <input class="input-small" type="text" /> </div> </div> </form> </div> </div> </div> <div class="accordion-group"> <div class="accordion-heading"> <a class="accordion-toggle" data-toggle="collapse" data-parent="#searchAccordion" href="#collapseTwo">TAB 11 – Captive Information</a> </div> <div id="collapseTwo" class="accordion-body collapse"> <div class="accordion-inner"> <form class="form-inline"> <div class="row-fluid"> <div class="span4"> <label>Address</label> <input class="input-large" type="text" /> </div> <div class="span4"> <label>Assessor</label> <input class="input-medium typeahead" id="taAssessor" type="text" data-provide="typeahead" autocomplete="off" /> </div> <div class="span4"> <label>Client</label> <input class="input-large typeahead" id="taClient" type="text" data-provide="typeahead" autocomplete="off" /> </div> </div> <div class="row-fluid"> <div class="span4"> <label>Status</label> <input class="input-medium typeahead" id="taStatus" type="text" data-provide="typeahead" autocomplete="off" /> </div> <div class="span4"> <label>Type</label> <input class="input-large typeahead" id="taType" type="text" data-provide="typeahead" autocomplete="off" /> </div> <div class="span4"> <label>Department</label> <input class="input-medium typeahead" id="taDepartment" type="text" data-provide="typeahead" autocomplete="off" /> </div> </div> <div class="row-fluid"> <div class="span3"> <label>Client Ref</label> <input class="input-small" type="text" /> </div> <div class="span3"> <label>PO Number</label> <input class="input-small" type="text" /> </div> </div> </form> </div> </div> </div> <div class="accordion-group"> <div class="accordion-heading"> <a class="accordion-toggle" data-toggle="collapse" data-parent="#searchAccordion" href="#collapseTwo">TAB 12– Excess Policy</a> </div> <div id="collapseTwo" class="accordion-body collapse"> <div class="accordion-inner"> <form class="form-inline"> <div class="row-fluid"> <div class="span4"> <label>Address</label> <input class="input-large" type="text" /> </div> <div class="span4"> <label>Assessor</label> <input class="input-medium typeahead" id="taAssessor" type="text" data-provide="typeahead" autocomplete="off" /> </div> <div class="span4"> <label>Client</label> <input class="input-large typeahead" id="taClient" type="text" data-provide="typeahead" autocomplete="off" /> </div> </div> <div class="row-fluid"> <div class="span4"> <label>Status</label> <input class="input-medium typeahead" id="taStatus" type="text" data-provide="typeahead" autocomplete="off" /> </div> <div class="span4"> <label>Type</label> <input class="input-large typeahead" id="taType" type="text" data-provide="typeahead" autocomplete="off" /> </div> <div class="span4"> <label>Department</label> <input class="input-medium typeahead" id="taDepartment" type="text" data-provide="typeahead" autocomplete="off" /> </div> </div> <div class="row-fluid"> <div class="span3"> <label>Client Ref</label> <input class="input-small" type="text" /> </div> <div class="span3"> <label>PO Number</label> <input class="input-small" type="text" /> </div> </div> </form> </div> </div> </div> <div class="accordion-group"> <div class="accordion-heading"> <a class="accordion-toggle" data-toggle="collapse" data-parent="#searchAccordion" href="#collapseTwo">TAB 13 – D&O Insurance</a> </div> <div id="collapseTwo" class="accordion-body collapse"> <div class="accordion-inner"> <form class="form-inline"> <div class="row-fluid"> <div class="span4"> <label>Address</label> <input class="input-large" type="text" /> </div> <div class="span4"> <label>Assessor</label> <input class="input-medium typeahead" id="taAssessor" type="text" data-provide="typeahead" autocomplete="off" /> </div> <div class="span4"> <label>Client</label> <input class="input-large typeahead" id="taClient" type="text" data-provide="typeahead" autocomplete="off" /> </div> </div> <div class="row-fluid"> <div class="span4"> <label>Status</label> <input class="input-medium typeahead" id="taStatus" type="text" data-provide="typeahead" autocomplete="off" /> </div> <div class="span4"> <label>Type</label> <input class="input-large typeahead" id="taType" type="text" data-provide="typeahead" autocomplete="off" /> </div> <div class="span4"> <label>Department</label> <input class="input-medium typeahead" id="taDepartment" type="text" data-provide="typeahead" autocomplete="off" /> </div> </div> <div class="row-fluid"> <div class="span3"> <label>Client Ref</label> <input class="input-small" type="text" /> </div> <div class="span3"> <label>PO Number</label> <input class="input-small" type="text" /> </div> </div> </form> </div> </div> </div> <div class="accordion-group"> <div class="accordion-heading"> <a class="accordion-toggle" data-toggle="collapse" data-parent="#searchAccordion" href="#collapseTwo">TAB 14 – Financial Information</a> </div> <div id="collapseTwo" class="accordion-body collapse"> <div class="accordion-inner"> <form class="form-inline"> <div class="row-fluid"> <div class="span4"> <label>Address</label> <input class="input-large" type="text" /> </div> <div class="span4"> <label>Assessor</label> <input class="input-medium typeahead" id="taAssessor" type="text" data-provide="typeahead" autocomplete="off" /> </div> <div class="span4"> <label>Client</label> <input class="input-large typeahead" id="taClient" type="text" data-provide="typeahead" autocomplete="off" /> </div> </div> <div class="row-fluid"> <div class="span4"> <label>Status</label> <input class="input-medium typeahead" id="taStatus" type="text" data-provide="typeahead" autocomplete="off" /> </div> <div class="span4"> <label>Type</label> <input class="input-large typeahead" id="taType" type="text" data-provide="typeahead" autocomplete="off" /> </div> <div class="span4"> <label>Department</label> <input class="input-medium typeahead" id="taDepartment" type="text" data-provide="typeahead" autocomplete="off" /> </div> </div> <div class="row-fluid"> <div class="span3"> <label>Client Ref</label> <input class="input-small" type="text" /> </div> <div class="span3"> <label>PO Number</label> <input class="input-small" type="text" /> </div> </div> </form> </div> </div> </div> <div class="accordion-group"> <div class="accordion-heading"> <a class="accordion-toggle" data-toggle="collapse" data-parent="#searchAccordion" href="#collapseTwo">TAB 15 – Member Certification</a> </div> <div id="collapseTwo" class="accordion-body collapse"> <div class="accordion-inner"> <form class="form-inline"> <div class="row-fluid"> <div class="span4"> <label>Address</label> <input class="input-large" type="text" /> </div> <div class="span4"> <label>Assessor</label> <input class="input-medium typeahead" id="taAssessor" type="text" data-provide="typeahead" autocomplete="off" /> </div> <div class="span4"> <label>Client</label> <input class="input-large typeahead" id="taClient" type="text" data-provide="typeahead" autocomplete="off" /> </div> </div> <div class="row-fluid"> <div class="span4"> <label>Status</label> <input class="input-medium typeahead" id="taStatus" type="text" data-provide="typeahead" autocomplete="off" /> </div> <div class="span4"> <label>Type</label> <input class="input-large typeahead" id="taType" type="text" data-provide="typeahead" autocomplete="off" /> </div> <div class="span4"> <label>Department</label> <input class="input-medium typeahead" id="taDepartment" type="text" data-provide="typeahead" autocomplete="off" /> </div> </div> <div class="row-fluid"> <div class="span3"> <label>Client Ref</label> <input class="input-small" type="text" /> </div> <div class="span3"> <label>PO Number</label> <input class="input-small" type="text" /> </div> </div> </form> </div> </div> </div> <div class="accordion-group"> <div class="accordion-heading"> <a class="accordion-toggle" data-toggle="collapse" data-parent="#searchAccordion" href="#collapse16">TAB 16 – Who Completed this Form?</a> </div> <div id="collapse16" class="accordion-body collapse"> <div class="accordion-inner"> <form class="form-inline"> <div class="row"> <div class="col-md-4 col-sm-12"> <label>Name</label> <input class="input-large" type="text" /> </div> </div> <div class="row"> <div class="col-md-6 col-sm-12"> <label>Company/Member Name</label> <input class="input-large typeahead" id="taAssessor" type="text" data-provide="typeahead" autocomplete="off" /> </div> <div class="col-md-6 col-sm-12"> <label>Address</label> <input class="input-large typeahead" id="taClient" type="text" data-provide="typeahead" autocomplete="off" /> </div> </div> <div class="row"> <div class="col-md-4 col-sm-12"> <label>City</label> <input class="input-large typeahead" id="taStatus" type="text" data-provide="typeahead" autocomplete="off" /> </div> <div class="col-md-4 col-sm-12"> <label>State</label> <input class="input-large typeahead" id="taType" type="text" data-provide="typeahead" autocomplete="off" /> </div> <div class="col-md-4 col-sm-12"> <label>Zip</label> <input class="input-large typeahead" id="taDepartment" type="text" data-provide="typeahead" autocomplete="off" /> </div> </div> <div class="row"> <div class="col-md-4 col-sm-12"> <label>Telephone Number</label> <input class="input-large" type="text" /> </div> <div class="col-md-4 col-sm-12"> <label>Facsimile Number</label> <input class="input-large" type="text" /> </div> <div class="col-md-4 col-sm-12"> <label>Email Address</label> <input class="input-large" type="text" /> </div> </div> </form> </div> </div> </div> </div> </div> </div> </div> </div> </body>