<link href="//netdna.bootstrapcdn.com/bootstrap/3.0.0/css/bootstrap.min.css" rel="stylesheet" id="bootstrap-css"> <script src="//netdna.bootstrapcdn.com/bootstrap/3.0.0/js/bootstrap.min.js"></script> <script src="//code.jquery.com/jquery-1.11.1.min.js"></script> <!------ Include the above in your HEAD tag ----------> <!-- The MIT License (MIT) Copyright (c) 2015 William Hilton Permission is hereby granted, free of charge, to any person obtaining a copy of this software and associated documentation files (the "Software"), to deal in the Software without restriction, including without limitation the rights to use, copy, modify, merge, publish, distribute, sublicense, and/or sell copies of the Software, and to permit persons to whom the Software is furnished to do so, subject to the following conditions: The above copyright notice and this permission notice shall be included in all copies or substantial portions of the Software. THE SOFTWARE IS PROVIDED "AS IS", WITHOUT WARRANTY OF ANY KIND, EXPRESS OR IMPLIED, INCLUDING BUT NOT LIMITED TO THE WARRANTIES OF MERCHANTABILITY, FITNESS FOR A PARTICULAR PURPOSE AND NONINFRINGEMENT. IN NO EVENT SHALL THE AUTHORS OR COPYRIGHT HOLDERS BE LIABLE FOR ANY CLAIM, DAMAGES OR OTHER LIABILITY, WHETHER IN AN ACTION OF CONTRACT, TORT OR OTHERWISE, ARISING FROM, OUT OF OR IN CONNECTION WITH THE SOFTWARE OR THE USE OR OTHER DEALINGS IN THE SOFTWARE. --> <!-- Vendor libraries --> <link rel="stylesheet" href="http://maxcdn.bootstrapcdn.com/font-awesome/4.3.0/css/font-awesome.min.css"> <script type="text/javascript" src="http://cdn.jsdelivr.net/jquery.validation/1.13.1/jquery.validate.min.js"></script> <!-- If you're using Stripe for payments --> <script type="text/javascript" src="https://js.stripe.com/v2/"></script> <!-- Credit card form --> <div class="container"> <div class="pagination-centered"> <div class="row"> <div class="col-xs-12 col-md-4"> <div class="panel panel-primary"> <div class="panel-heading" style="border-bottom: 5px solid transparent;"> <h3 class="panel-title">First Notice Of Loss</h3> <a class="btn btn-sm btn-info pull-right" href="#"><span class="glyphicon glyphicon-search"></span> Search</a> </div> <div class="panel-body"> <form role="form"> <div class="row"> <div class="col-xs-12"> <div class="form-group"> <label for="cardNumber">CLAIMS REFERENCE NUMBER</label> <div class="form-group"> <input type="text" class="form-control" name="cardNumber" placeholder="Claims Reference Number" required autofocus /> </div> </div> </div> </div> <div class="row"> <div class="col-xs-12"> <button class="btn btn-success" type="submit">Resume</button> </div> </div> </form> </div> </div> </div> </div> </div> </div>

/* Padding - just for asthetics on Bootsnipp.com */ body { margin-top:20px; } .panel-title {display: inline;font-weight: bold;}