<!DOCTYPE html>
<html>
<head>
<meta charset='utf-8'>
<title>Monstrosity</title>
<link rel="stylesheet" href="https://cdnjs.cloudflare.com/ajax/libs/twitter-bootstrap/4.0.0/css/bootstrap.min.css" />
<link rel="stylesheet" href="https://cdnjs.cloudflare.com/ajax/libs/font-awesome/4.7.0/css/font-awesome.min.css" />
</head>
<body>
<script src="https://cdnjs.cloudflare.com/ajax/libs/jquery/3.3.1/jquery.min.js"></script>
<script src="https://cdnjs.cloudflare.com/ajax/libs/popper.js/1.12.9/umd/popper.min.js"></script>
<script src="https://cdnjs.cloudflare.com/ajax/libs/twitter-bootstrap/4.0.0/js/bootstrap.min.js"></script>
<script>
(function () {
const str = `
<div class="tab-content">
<div role="tabpanel" class="tab-pane active" id="tab-inventory">
<div class="row tp-wrapper">
<div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
<h1>Kies verzekering(en)</h1>
<div class="row verzekeringen-mogelijk-row">
<div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
<h4>woonpakket</h4>
<hr>
<div class="verzekering-mogelijk col-lg-2 col-md-3 col-sm-4 col-xs-6 "
data-tab="house" data-productid="1">
<div class="well active active-well">
<div class="row">
<div class="col-lg-8 col-md-8 col-sm-8 col-xs-8">
<i class="fa fa-home fa-3x"></i>
</div>
<div class="col-lg-4 col-md-4 col-sm-4 col-xs-4">
<button type="button"
class="plus-button plus-minus-button btn btn-default"><i
class="fa fa-plus fa-lg"></i></button>
<button type="button"
class="minus-button plus-minus-button btn btn-default"><i
class="fa fa-minus fa-lg"></i></button>
</div>
</div>
<div class="row label-row">
<div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
<label>Woonhuis</label> <span
class="amount-value badge">1</span>
</div>
</div>
</div>
</div>
<div class="verzekering-mogelijk col-lg-2 col-md-3 col-sm-4 col-xs-6 "
data-tab="responsibility" data-productid="2">
<div class="well active active-well">
<div class="row">
<div class="col-lg-8 col-md-8 col-sm-8 col-xs-8">
<i class="fa fa-file-text fa-3x"></i>
</div>
<div class="col-lg-4 col-md-4 col-sm-4 col-xs-4">
<button type="button"
class="plus-button plus-minus-button btn btn-default"><i
class="fa fa-plus fa-lg"></i></button>
<button type="button"
class="minus-button plus-minus-button btn btn-default"><i
class="fa fa-minus fa-lg"></i></button>
</div>
</div>
<div class="row label-row">
<div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
<label>Aansprakelijkheid</label> <span
class="amount-value badge">1</span>
</div>
</div>
</div>
</div>
<div class="verzekering-mogelijk col-lg-2 col-md-3 col-sm-4 col-xs-6 "
data-tab="house" data-productid="3">
<div class="well active active-well">
<div class="row">
<div class="col-lg-8 col-md-8 col-sm-8 col-xs-8">
<i class="fa fa-television fa-3x"></i>
</div>
<div class="col-lg-4 col-md-4 col-sm-4 col-xs-4">
<button type="button"
class="plus-button plus-minus-button btn btn-default"><i
class="fa fa-plus fa-lg"></i></button>
<button type="button"
class="minus-button plus-minus-button btn btn-default"><i
class="fa fa-minus fa-lg"></i></button>
</div>
</div>
<div class="row label-row">
<div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
<label>Inboedel</label> <span
class="amount-value badge">1</span>
</div>
</div>
</div>
</div>
<div class="verzekering-mogelijk col-lg-2 col-md-3 col-sm-4 col-xs-6 hidden"
data-tab="house" data-productid="4">
<div class="well active active-well">
<div class="row">
<div class="col-lg-8 col-md-8 col-sm-8 col-xs-8">
<i class="fa fa-home fa-3x"></i>
</div>
<div class="col-lg-4 col-md-4 col-sm-4 col-xs-4">
<button type="button"
class="plus-button plus-minus-button btn btn-default"><i
class="fa fa-plus fa-lg"></i></button>
<button type="button"
class="minus-button plus-minus-button btn btn-default"><i
class="fa fa-minus fa-lg"></i></button>
</div>
</div>
<div class="row label-row">
<div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
<label>Buitenshuisdekking</label> <span
class="amount-value badge">1</span>
</div>
</div>
</div>
</div>
<div class="verzekering-mogelijk col-lg-2 col-md-3 col-sm-4 col-xs-6 "
data-tab="legal-aid" data-productid="5">
<div class="well ">
<div class="row">
<div class="col-lg-8 col-md-8 col-sm-8 col-xs-8">
<i class="fa fa-balance-scale fa-3x"></i>
</div>
<div class="col-lg-4 col-md-4 col-sm-4 col-xs-4">
<button type="button"
class="plus-button plus-minus-button btn btn-default"><i
class="fa fa-plus fa-lg"></i></button>
<button type="button"
class="minus-button plus-minus-button btn btn-default"><i
class="fa fa-minus fa-lg"></i></button>
</div>
</div>
<div class="row label-row">
<div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
<label>Rechtsbijstand</label> <span
class="amount-value badge"></span>
</div>
</div>
</div>
</div>
<div class="verzekering-mogelijk col-lg-2 col-md-3 col-sm-4 col-xs-6 "
data-tab="accident-insurance" data-productid="6">
<div class="well ">
<div class="row">
<div class="col-lg-8 col-md-8 col-sm-8 col-xs-8">
<i class="fa fa-medkit fa-3x"></i>
</div>
<div class="col-lg-4 col-md-4 col-sm-4 col-xs-4">
<button type="button"
class="plus-button plus-minus-button btn btn-default"><i
class="fa fa-plus fa-lg"></i></button>
<button type="button"
class="minus-button plus-minus-button btn btn-default"><i
class="fa fa-minus fa-lg"></i></button>
</div>
</div>
<div class="row label-row">
<div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
<label>(Gezins)ongevallen</label> <span
class="amount-value badge"></span>
</div>
</div>
</div>
</div>
<div class="verzekering-mogelijk col-lg-2 col-md-3 col-sm-4 col-xs-6 "
data-tab="travel-and-cancellation" data-productid="7">
<div class="well active active-well">
<div class="row">
<div class="col-lg-8 col-md-8 col-sm-8 col-xs-8">
<i class="fa fa-suitcase fa-3x"></i>
</div>
<div class="col-lg-4 col-md-4 col-sm-4 col-xs-4">
<button type="button"
class="plus-button plus-minus-button btn btn-default"><i
class="fa fa-plus fa-lg"></i></button>
<button type="button"
class="minus-button plus-minus-button btn btn-default"><i
class="fa fa-minus fa-lg"></i></button>
</div>
</div>
<div class="row label-row">
<div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
<label>Reis & annulering</label> <span
class="amount-value badge">1</span>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row verzekeringen-mogelijk-row">
<div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
<h4>voertuigen</h4>
<hr>
<div class="verzekering-mogelijk col-lg-2 col-md-3 col-sm-4 col-xs-6 "
data-tab="car" data-productid="9">
<div class="well active active-well">
<div class="row">
<div class="col-lg-8 col-md-8 col-sm-8 col-xs-8">
<i class="fa fa-car fa-3x"></i>
</div>
<div class="col-lg-4 col-md-4 col-sm-4 col-xs-4">
<button type="button"
class="plus-button plus-minus-button btn btn-default"><i
class="fa fa-plus fa-lg"></i></button>
<button type="button"
class="minus-button plus-minus-button btn btn-default"><i
class="fa fa-minus fa-lg"></i></button>
</div>
</div>
<div class="row label-row">
<div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
<label>Auto</label> <span
class="amount-value badge">1</span>
</div>
</div>
</div>
</div>
<div class="verzekering-mogelijk col-lg-2 col-md-3 col-sm-4 col-xs-6 "
data-tab="car-oldtimer" data-productid="10">
<div class="well ">
<div class="row">
<div class="col-lg-8 col-md-8 col-sm-8 col-xs-8">
<i class="fa fa-car fa-3x"></i>
</div>
<div class="col-lg-4 col-md-4 col-sm-4 col-xs-4">
<button type="button"
class="plus-button plus-minus-button btn btn-default"><i
class="fa fa-plus fa-lg"></i></button>
<button type="button"
class="minus-button plus-minus-button btn btn-default"><i
class="fa fa-minus fa-lg"></i></button>
</div>
</div>
<div class="row label-row">
<div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
<label>Oldtimer auto</label> <span
class="amount-value badge"></span>
</div>
</div>
</div>
</div>
<div class="verzekering-mogelijk col-lg-2 col-md-3 col-sm-4 col-xs-6 "
data-tab="motorcycle" data-productid="11">
<div class="well ">
<div class="row">
<div class="col-lg-8 col-md-8 col-sm-8 col-xs-8">
<i class="fa fa-motorcycle fa-3x"></i>
</div>
<div class="col-lg-4 col-md-4 col-sm-4 col-xs-4">
<button type="button"
class="plus-button plus-minus-button btn btn-default"><i
class="fa fa-plus fa-lg"></i></button>
<button type="button"
class="minus-button plus-minus-button btn btn-default"><i
class="fa fa-minus fa-lg"></i></button>
</div>
</div>
<div class="row label-row">
<div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
<label>Motor</label> <span
class="amount-value badge"></span>
</div>
</div>
</div>
</div>
<div class="verzekering-mogelijk col-lg-2 col-md-3 col-sm-4 col-xs-6 "
data-tab="motorcycle-oldtimer" data-productid="12">
<div class="well ">
<div class="row">
<div class="col-lg-8 col-md-8 col-sm-8 col-xs-8">
<i class="fa fa-motorcycle fa-3x"></i>
</div>
<div class="col-lg-4 col-md-4 col-sm-4 col-xs-4">
<button type="button"
class="plus-button plus-minus-button btn btn-default"><i
class="fa fa-plus fa-lg"></i></button>
<button type="button"
class="minus-button plus-minus-button btn btn-default"><i
class="fa fa-minus fa-lg"></i></button>
</div>
</div>
<div class="row label-row">
<div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
<label>Oldtimer motor</label> <span
class="amount-value badge"></span>
</div>
</div>
</div>
</div>
<div class="verzekering-mogelijk col-lg-2 col-md-3 col-sm-4 col-xs-6 "
data-tab="van" data-productid="13">
<div class="well ">
<div class="row">
<div class="col-lg-8 col-md-8 col-sm-8 col-xs-8">
<i class="fa fa-truck fa-3x"></i>
</div>
<div class="col-lg-4 col-md-4 col-sm-4 col-xs-4">
<button type="button"
class="plus-button plus-minus-button btn btn-default"><i
class="fa fa-plus fa-lg"></i></button>
<button type="button"
class="minus-button plus-minus-button btn btn-default"><i
class="fa fa-minus fa-lg"></i></button>
</div>
</div>
<div class="row label-row">
<div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
<label>Bestelauto</label> <span
class="amount-value badge"></span>
</div>
</div>
</div>
</div>
<div class="verzekering-mogelijk col-lg-2 col-md-3 col-sm-4 col-xs-6 "
data-tab="caravan" data-productid="14">
<div class="well ">
<div class="row">
<div class="col-lg-8 col-md-8 col-sm-8 col-xs-8">
<i class="fa fa-car fa-3x"></i>
</div>
<div class="col-lg-4 col-md-4 col-sm-4 col-xs-4">
<button type="button"
class="plus-button plus-minus-button btn btn-default"><i
class="fa fa-plus fa-lg"></i></button>
<button type="button"
class="minus-button plus-minus-button btn btn-default"><i
class="fa fa-minus fa-lg"></i></button>
</div>
</div>
<div class="row label-row">
<div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
<label>Caravan</label> <span
class="amount-value badge"></span>
</div>
</div>
</div>
</div>
<div class="verzekering-mogelijk col-lg-2 col-md-3 col-sm-4 col-xs-6 "
data-tab="camper" data-productid="18">
<div class="well ">
<div class="row">
<div class="col-lg-8 col-md-8 col-sm-8 col-xs-8">
<i class="fa fa-car fa-3x"></i>
</div>
<div class="col-lg-4 col-md-4 col-sm-4 col-xs-4">
<button type="button"
class="plus-button plus-minus-button btn btn-default"><i
class="fa fa-plus fa-lg"></i></button>
<button type="button"
class="minus-button plus-minus-button btn btn-default"><i
class="fa fa-minus fa-lg"></i></button>
</div>
</div>
<div class="row label-row">
<div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
<label>Kampeerauto</label> <span
class="amount-value badge"></span>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row verzekeringen-mogelijk-row">
<div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
<h4>overig</h4>
<hr>
<div class="verzekering-mogelijk col-lg-2 col-md-3 col-sm-4 col-xs-6 "
data-tab="" data-productid="15">
<div class="well ">
<div class="row">
<div class="col-lg-8 col-md-8 col-sm-8 col-xs-8">
<i class="fa fa-medkit fa-3x"></i>
</div>
<div class="col-lg-4 col-md-4 col-sm-4 col-xs-4">
<button type="button"
class="plus-button plus-minus-button btn btn-default"><i
class="fa fa-plus fa-lg"></i></button>
<button type="button"
class="minus-button plus-minus-button btn btn-default"><i
class="fa fa-minus fa-lg"></i></button>
</div>
</div>
<div class="row label-row">
<div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
<label>Kortlopende reis</label> <span
class="amount-value badge"></span>
</div>
</div>
</div>
</div>
<div class="verzekering-mogelijk col-lg-2 col-md-3 col-sm-4 col-xs-6 "
data-tab="responsibility" data-productid="16">
<div class="well ">
<div class="row">
<div class="col-lg-8 col-md-8 col-sm-8 col-xs-8">
<i class="fa fa-camera fa-3x"></i>
</div>
<div class="col-lg-4 col-md-4 col-sm-4 col-xs-4">
<button type="button"
class="plus-button plus-minus-button btn btn-default"><i
class="fa fa-plus fa-lg"></i></button>
<button type="button"
class="minus-button plus-minus-button btn btn-default"><i
class="fa fa-minus fa-lg"></i></button>
</div>
</div>
<div class="row label-row">
<div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
<label>Kostbaarheden</label> <span
class="amount-value badge"></span>
</div>
</div>
</div>
</div>
<div class="verzekering-mogelijk col-lg-2 col-md-3 col-sm-4 col-xs-6 "
data-tab="house" data-productid="17">
<div class="well ">
<div class="row">
<div class="col-lg-8 col-md-8 col-sm-8 col-xs-8">
<i class="fa fa-mobile fa-3x"></i>
</div>
<div class="col-lg-4 col-md-4 col-sm-4 col-xs-4">
<button type="button"
class="plus-button plus-minus-button btn btn-default"><i
class="fa fa-plus fa-lg"></i></button>
<button type="button"
class="minus-button plus-minus-button btn btn-default"><i
class="fa fa-minus fa-lg"></i></button>
</div>
</div>
<div class="row label-row">
<div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
<label>Mobiele apparatuur</label> <span
class="amount-value badge"></span>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div> </div>
<div role="tabpanel" class="tab-pane" id="tab-general-information">
<div class="row tp-wrapper">
<div class="col-sm-12">
<form method="POST" action="https://app.example.net/app/generalinfo/store" accept-charset="UTF-8" class="form-horizontal"><input name="_token" type="hidden" value="LSJ7UMmOiFRd1ufN0UBhb4WuSKg907ZGCfXiwIym">
<div class="row">
<div class="col-lg-8 col-md-8 col-sm-12 col-xs-12">
<div class="panel panel-default">
<div class="panel-heading">Verzekeringnemer</div>
<div class="panel-body">
<p>De gegevens van de verzekeringnemer worden hier ingevuld</p>
<br/>
<div class="row">
<div class="col-lg-6 col-md-6 col-sm-12 col-xs-12">
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="initials" class="control-label">Relatienummer</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control" name="initials" type="text" id="initials">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="lastname" class="control-label">Vergelijkingsnummer</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control" name="lastname" type="text" id="lastname">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="birthdate" class="control-label required">Geboortedatum</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon"><i class="fa fa-calendar"></i></div>
<input class="form-control required" placeholder="dd-mm-jjjj" required="required" name="birthdate" type="text" value="09-05-1988" id="birthdate">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="gender" class="control-label required">Geslacht</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input id="gender_male" checked="checked" name="gender" type="radio" value="male">
<label for="gender_male" class="control-label">Man</label>
<input id="gender_female" name="gender" type="radio" value="female">
<label for="gender_female" class="control-label">Vrouw</label>
</div>
</div>
<hr/>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="family_situation" class="control-label required">Gezinssituatie</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control required" required="required" id="family_situation" name="family_situation"><option value="single_without_children" selected="selected">Alleenstaande zonder kinderen</option><option value="single_with_children">Alleenstaande met kinderen</option><option value="family_without_children">Gezin zonder kinderen</option><option value="family_with_children">Gezin met kinderen</option></select>
</div>
</div>
<div id="general_info_partner_birthdate" class="form-group">
<input type="hidden" name="partner_initials" value=""/>
<input type="hidden" name="partner_lastname" value=""/>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="partner_birthdate" class="control-label">Geboortedatum partner</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon"><i class="fa fa-calendar"></i></div>
<input class="form-control" placeholder="dd-mm-jjjj" name="partner_birthdate" type="text" id="partner_birthdate">
</div>
</div>
</div>
</div>
<hr/>
<div id="general_info_amount_children" class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="amount_children" class="control-label">Aantal kinderen</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control" min="1" max="8" name="amount_children" type="number" value="0" id="amount_children">
</div>
</div>
<div id="general-info-children-repeater" class="repeater"
data-children="[]">
<div data-repeater-list="general-info-children-list">
<div class="form-group" data-repeater-item style="display:none;">
<div class="repeater-label-col col-lg-4 col-md-4 col-xs-5">
<label>Geboortedatum {index}</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon"><i class="fa fa-calendar"></i></div>
<input type="text" name="geboortedatum" class="form-control"
placeholder="dd-mm-jjjj"/>
</div>
</div>
<input class="remove-repeater-item hidden" data-repeater-delete
type="button" value="Delete"/>
</div>
<input class="add-repeater-item hidden" data-repeater-create type="button"
value="Add"/>
</div>
</div>
</div>
<div class="col-lg-6 col-md-6 col-sm-12 col-xs-12">
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="postcode" class="control-label required">Postcode</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control required" required="required" name="postcode" type="text" value="7908NV" id="postcode">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="housenumber" class="control-label required">Huisnummer en toevoeging</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control required" required="required" name="housenumber" type="text" value="37" id="housenumber">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="street" class="control-label">Straat</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control api-fillable" name="street" type="text" value="De Drift" id="street">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="city" class="control-label">Woonplaats</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control api-fillable" name="city" type="text" value="Hoogeveen" id="city">
</div>
</div>
<hr/>
<div class="form-group">
<div class="col-xs-12">
<p class="text-right">Selecteer API voor de automatischeaanvulling woonhuisgegevens:</p>
<div class="btn-group pull-right" data-toggle="buttons">
<label class="btn btn-default active">
<input type="radio" name="options" id="option1" checked> Infofolio
</label>
<label class="btn btn-default">
<input type="radio" name="options" id="option2"> Kadaster
</label>
</div>
</div>
</div>
<hr/>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="calculation_date" class="control-label required">Berekendatum</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon"><i class="fa fa-calendar"></i></div>
<input class="form-control required" placeholder="dd-mm-jjjj" required="required" name="calculation_date" type="text" value="28-03-2018" id="calculation_date">
</div>
</div>
</div>
<hr/>
<div class="form-group">
<div class="col-xs-12">
<p>Weging van de premie</p>
<div style="padding:0 15px;">
<input id="premium-points-slider" class="no-user-select full-size" type="text"
data-setval=""/>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="col-lg-4 col-md-4 col-sm-12 col-xs-12">
<div class="panel panel-default streetview-panel">
<div class="panel-heading">Streetview</div>
<div class="panel-body">
<div class="row" id="streetview-row">
<div class="col-xs-12">
<img class="housephoto full-size">
</div>
</div>
<div class="row">
<div class="col-xs-12">
<br/>
<span class="streetview-street"></span> <span class="streetview-housenumber"></span><br/>
<span class="streetview-postalcode"></span> <span class="streetview-city"></span><br/>
<span class="streetview-family-situation"></span>
<hr/>
</div>
</div>
<div class="row form-color-legend"></div> </div>
</div>
</div>
</div>
</form>
</div>
</div> </div>
<div role="tabpanel" class="tab-pane" id="tab-house">
<div class="row tp-wrapper">
<div class="col-sm-12">
<form method="POST" action="https://app.example.net/app/house/store" accept-charset="UTF-8" class="form-horizontal"><input name="_token" type="hidden" value="LSJ7UMmOiFRd1ufN0UBhb4WuSKg907ZGCfXiwIym">
<div class="row">
<div class="col-lg-8 col-md-8 col-sm-12 col-xs-12">
<div class="panel panel-default">
<div class="panel-heading pull-left col-xs-12">
<div class="pull-left">Te verzekeren objecten; en/of waar de inboedel zich bevindt</div>
</div>
<div class="panel-body">
<p>De gegevens van het woonhuis zijn altijd nodig voor een woonhuis- en/of
inboedelverzekering</p>
<br/>
<div class="row">
<div class="col-lg-6 col-md-6 col-sm-12 col-xs-12">
<input type="hidden" name="start_date" value="28-03-2018"/>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="house_type" class="control-label">Type woning</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control api-fillable" id="house_type" name="house_type"><option value="vrijstaande-woning">Vrijstaande woning</option><option value="rijtjeswoning">Rijtjeswoning</option><option value="twee-onder-een-kap" selected="selected">Twee-onder-één-kap</option><option value="hoekwoning">Hoekwoning</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="buildyear" class="control-label">Bouwjaar</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control api-fillable" placeholder="jjjj" name="buildyear" type="text" value="1991" id="buildyear">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="surface_area" class="control-label">Vloeroppervlak</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon">m²</div>
<input class="form-control api-fillable" name="surface_area" type="text" value="155" id="surface_area">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="contents" class="control-label">Inhoud</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon">m³</div>
<input class="form-control api-fillable" name="contents" type="text" value="458" id="contents">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="roof_construction_type" class="control-label">Bouwaard dak</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="roof_construction_type" name="roof_construction_type"><option value="dakpannen" selected="selected">Dakpannen</option><option value="bitumen">Bitumen</option><option value="mastiek">Mastiek</option><option value="riet">Riet</option><option value="leisteen">Leisteen</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="roof_kind" class="control-label">Soort dak</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="roof_kind" name="roof_kind"><option value="schuin" selected="selected">Schuin</option><option value="plat">Plat</option></select>
</div>
</div>
<input type="hidden" name="has_chimney" value="geen-rookkanaal-voor-open-haard-of-kachel"/>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="walls_construction_type" class="control-label">Bouwaard muren</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="walls_construction_type" name="walls_construction_type"><option value="steen-hard" selected="selected">Steen/hard</option><option value="hout">Hout</option></select>
</div>
</div>
</div>
<div class="col-lg-6 col-md-6 col-sm-12 col-xs-12">
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="amount_rooms" class="control-label">Aantal kamers</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control" name="amount_rooms" type="text" value="4" id="amount_rooms">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="house_improvements" class="control-label">Verbeteringen woning</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="house_improvements" name="house_improvements"><option value="ja">Ja</option><option value="nee" selected="selected">Nee</option></select>
</div>
</div>
<div class="house-improvements">
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="bathroom_type" class="control-label">Badkamer</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="bathroom_type" name="bathroom_type"><option value="eenvoudig">Eenvoudig</option><option value="normaal" selected="selected">Normaal</option><option value="luxe">Luxe</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="kitchen_type" class="control-label">Keuken</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="kitchen_type" name="kitchen_type"><option value="eenvoudig">Eenvoudig</option><option value="normaal" selected="selected">Normaal</option><option value="luxe">Luxe</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="house_other_completions" class="control-label">Overige afbouw</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="house_other_completions" name="house_other_completions"><option value="ja">Ja</option><option value="nee" selected="selected">Nee</option></select>
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="rental_house" class="control-label">Huurwoning</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="rental_house" name="rental_house"><option value="ja">Ja</option><option value="nee" selected="selected">Nee</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="house_development_plan" class="control-label">Bestemming woning</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="house_development_plan" name="house_development_plan"><option value="particulier-gebruik" selected="selected">Particulier gebruik</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="house_expansion" class="control-label">Bijgebouwd</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="house_expansion" name="house_expansion"><option value="nee" selected="selected">Nee</option><option value="ja-kleiner-dan-25m2">Ja, kleiner dan 25m²</option><option value="ja-groter-dan-25m2">Ja, groter dan 25m²</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="house_expansion_surface_area" class="control-label">Opp. bijgebouw</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon">m²</div>
<input class="form-control" name="house_expansion_surface_area" type="text" value="0" id="house_expansion_surface_area">
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="col-lg-4 col-md-4 col-sm-12 col-xs-12">
<div class="panel panel-default streetview-panel">
<div class="panel-heading">Streetview</div>
<div class="panel-body">
<div class="row">
<div class="col-xs-12">
<img class="housephoto full-size">
</div>
</div>
<div class="row">
<div class="col-xs-12">
<span class="streetview-street"></span> <span class="streetview-housenumber"></span><br/>
<span class="streetview-postalcode"></span> <span class="streetview-city"></span><br/>
<span class="streetview-family-situation"></span>
<hr/>
</div>
</div>
<div class="row form-color-legend"></div> </div>
</div>
</div>
</div>
<div class="row">
<div class="col-xs-12">
<div class="panel panel-default">
<div class="panel-heading">Aanvullende gegevens woonhuis en inboedel</div>
<div class="panel-body inputinlabel">
<div class="row">
<div class="col-md-4 col-sm-12 col-xs-12">
<div class="form-group">
<div class="col-lg-5 col-md-5 col-xs-5">
<label for="netto_month_income_main_breadwinner" class="control-label">Netto maandinkomen hoofdkostwinner</label>
</div>
<div class="col-lg-7 col-md-7 col-xs-7">
<select class="form-control required" id="netto_month_income_main_breadwinner" name="netto_month_income_main_breadwinner"><option value="">Selecteer maandinkomen</option><option value="<1000">< € 1.000</option><option value="1000-2000" selected="selected">€ 2.000</option><option value="2000-3000">€ 3.000</option><option value="3000-4850">€ 4.850</option><option value=">4850">> € 4.850</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-5 col-md-5 col-xs-5">
<label for="insure_glass" class="control-label">Glas meeverzekeren</label>
</div>
<div class="col-lg-7 col-md-7 col-xs-7">
<select class="form-control" id="insure_glass" name="insure_glass"><option value="ja" selected="selected">Ja</option><option value="nee">Nee</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-5 col-md-5 col-xs-5">
<label for="additional_risks_rent" class="control-label">Verhuur</label>
</div>
<div class="col-lg-7 col-md-7 col-xs-7">
<select class="form-control" id="additional_risks_rent" name="additional_risks_rent"><option value="geen-verhuur" selected="selected">Geen verhuur</option><option value="gedeeltelijke-verhuur">Gedeeltelijke verhuur</option><option value="volledige-verhuur">Volledige verhuur</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-5 col-md-5 col-xs-5">
<label for="additional_risks_solar_panels" class="control-label">Zonnepanelen</label>
</div>
<div class="col-lg-7 col-md-7 col-xs-7">
<select class="form-control" id="additional_risks_solar_panels" name="additional_risks_solar_panels"><option value="geen-zonnepanelen" selected="selected">Geen zonnepanelen</option><option value="zonnepanelen-meeverzekeren">Zonnepanelen meeverzekeren</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-5 col-md-5 col-xs-5">
<label for="additional_risks_ownership_renter_stake_option" class="control-label">Eigenaars- /Huurdersbelang</label>
</div>
<div class="col-lg-7 col-md-7 col-xs-7">
<select class="form-control" id="additional_risks_ownership_renter_stake_option" name="additional_risks_ownership_renter_stake_option"><option value="niet-van-toepassing" selected="selected">Niet van toepassing</option><option value="ja-standaard">Ja, standaard</option><option value="aangepaste-verzekerde-bedragen">Aangepaste verzekerde bedragen</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-5 col-md-5 col-xs-5">
<label for="additional_risks_ownership_renter_stake_value" class="control-label">Eigenaars- /Huurdersbelang</label>
</div>
<div class="col-lg-7 col-md-7 col-xs-7">
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control" name="additional_risks_ownership_renter_stake_value" type="text" id="additional_risks_ownership_renter_stake_value">
</div>
</div>
</div>
</div>
<div class="col-md-8 col-sm-12 col-xs-12">
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-12">
<label for="additional_risks_mobile_electronics_cover_option" class="control-label">Mobiele elektronicadekking (a.s.r.)</label>
</div>
<div class="col-lg-4 col-md-4 col-xs-6">
<select class="form-control" id="additional_risks_mobile_electronics_cover_option" name="additional_risks_mobile_electronics_cover_option"><option value="ja" selected="selected">Ja</option><option value="nee">Nee</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-12">
<label for="additional_risks_smartphone_tablet_cover_option" class="control-label">Smartphone en tablet (Unigarant)</label>
</div>
<div class="col-lg-4 col-md-4 col-xs-6">
<select class="form-control" id="additional_risks_smartphone_tablet_cover_option" name="additional_risks_smartphone_tablet_cover_option"><option value="ja" selected="selected">Ja</option><option value="nee">Nee</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-12">
<label for="additional_risks_outside_cover" class="control-label">Buitenshuisdekking</label>
</div>
<div class="col-lg-4 col-md-4 col-xs-12">
<select class="form-control" id="additional_risks_outside_cover" name="additional_risks_outside_cover"><option value="ja">Ja</option><option value="nee" selected="selected">Nee</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-12">
<label for="additional_risks_outside_nn_cover_option" class="control-label">Buitenshuisdekking (Nat. Ned.)</label>
</div>
<div class="col-lg-4 col-md-4 col-xs-12">
<select class="form-control" id="additional_risks_outside_nn_cover_option" name="additional_risks_outside_nn_cover_option"><option value="ja" selected="selected">Ja</option><option value="nee">Nee</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-12">
<label for="additional_risks_valuables_asr_cover_option" class="control-label">Kostbaarheden (a.s.r.)</label>
</div>
<div class="col-lg-4 col-md-4 col-xs-12">
<select class="form-control" id="additional_risks_valuables_asr_cover_option" name="additional_risks_valuables_asr_cover_option"><option value="ja">Ja</option><option value="nee" selected="selected">Nee</option></select>
</div>
<div class="col-lg-3 col-md-3 col-xs-6">
<select class="form-control" name="additional_risks_valuables_cover_value"><option value="-7500" selected="selected">€ 7.500</option><option value="-15500">€ 15.500</option><option value="-25500">€ 25.500</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-12">
<label for="additional_risks_valuables_option" class="control-label">Kostbaarheden</label>
</div>
<div class="col-lg-4 col-md-4 col-xs-12">
<select class="form-control" id="additional_risks_valuables_option" name="additional_risks_valuables_option"><option value="ja">Ja</option><option value="nee" selected="selected">Nee</option></select>
</div>
</div>
<div id="additional_risks_valuables_cover_subvalues">
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-12"></div>
<div class="col-lg-4 col-md-7 col-xs-12">
<label for="additional_risks_valuables_computer_value" class="control-label">Computerapparatuur</label>
</div>
<div class="col-lg-3 col-md-3 col-xs-6">
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control" name="additional_risks_valuables_computer_value" type="text" value="0" id="additional_risks_valuables_computer_value">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-12"></div>
<div class="col-lg-4 col-md-7 col-xs-12">
<label for="additional_risks_valuables_horloge_value" class="control-label">(Pols)horloges</label>
</div>
<div class="col-lg-3 col-md-3 col-xs-6">
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control" name="additional_risks_valuables_horloge_value" type="text" value="0" id="additional_risks_valuables_horloge_value">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-12"></div>
<div class="col-lg-4 col-md-7 col-xs-12">
<label for="additional_risks_valuables_music_value" class="control-label">Elektrisch versterkte muziekinstrumenten</label>
</div>
<div class="col-lg-3 col-md-3 col-xs-6">
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control" name="additional_risks_valuables_music_value" type="text" value="0" id="additional_risks_valuables_music_value">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-12"></div>
<div class="col-lg-4 col-md-7 col-xs-12">
<label for="additional_risks_valuables_jewellery_value" class="control-label">Lijfsieraden (excl. (pols)horloges)</label>
</div>
<div class="col-lg-3 col-md-3 col-xs-6">
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control" name="additional_risks_valuables_jewellery_value" type="text" value="0" id="additional_risks_valuables_jewellery_value">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-12"></div>
<div class="col-lg-4 col-md-7 col-xs-12">
<label for="additional_risks_valuables_film_value" class="control-label">Foto-, Film- en videoapparatuur</label>
</div>
<div class="col-lg-3 col-md-3 col-xs-6">
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control" name="additional_risks_valuables_film_value" type="text" value="0" id="additional_risks_valuables_film_value">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-12"></div>
<div class="col-lg-4 col-md-7 col-xs-12">
<label for="additional_risks_valuables_optical_value" class="control-label">Optische instrumenten</label>
</div>
<div class="col-lg-3 col-md-3 col-xs-6">
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control" name="additional_risks_valuables_optical_value" type="text" value="0" id="additional_risks_valuables_optical_value">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-12"></div>
<div class="col-lg-4 col-md-7 col-xs-12">
<label for="additional_risks_valuables_art_value" class="control-label">Kunst</label>
</div>
<div class="col-lg-3 col-md-3 col-xs-6">
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control" name="additional_risks_valuables_art_value" type="text" value="0" id="additional_risks_valuables_art_value">
</div>
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="furniture_insurance_security[]" class="control-label">Vrijwillige beveiliging</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="row">
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="furniture_insurance_security_veilig-wonen" name="furniture_insurance_security[]" type="checkbox" value="veilig-wonen">
<label for="furniture_insurance_security_veilig-wonen" class="control-label">Veilig Wonen</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="furniture_insurance_security_elektronisch-beveiligd-borg" name="furniture_insurance_security[]" type="checkbox" value="elektronisch-beveiligd-borg">
<label for="furniture_insurance_security_elektronisch-beveiligd-borg" class="control-label">Elektronisch beveiligd (BORG)</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="furniture_insurance_security_blusdeken-en-brandblusser" name="furniture_insurance_security[]" type="checkbox" value="blusdeken-en-brandblusser">
<label for="furniture_insurance_security_blusdeken-en-brandblusser" class="control-label">Blusdeken en brandblusser</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="furniture_insurance_security_rookmelder-per-verdieping" name="furniture_insurance_security[]" type="checkbox" value="rookmelder-per-verdieping">
<label for="furniture_insurance_security_rookmelder-per-verdieping" class="control-label">Rookmelder per verdieping</label>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-lg-6 col-md-6 col-sm-12 col-xs-12">
<div class="panel panel-default">
<div class="panel-heading">Risico's en voorwaarden woonhuis</div>
<div class="panel-body">
<div class="row">
<div class="col-xs-12">
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<button type="button" class="btn btn-default btn-xs pull-right ml5" data-toggle="modal"
data-target="#house-own-risk-modal"><i class="fa fa-info-circle"></i></button> <label for="house_insurance_own_risk" class="control-label">Eigen risico's</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="house_insurance_own_risk" name="house_insurance_own_risk"><option value="geen-eigen-risico-of-zo-laag-mogelijk" selected="selected">Geen eigen risico of zo laag mogelijk</option><option value="met-eigen-risico-maar-zo-laag-mogelijk">Met eigen risico, maar zo laag mogelijk</option><option value="met-eigen-risico-maar-zo-hoog-mogelijk">Met eigen risico, maar zo hoog mogelijk</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="house_insurance_own_risk_storm" class="control-label">Eigen risico storm</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="house_insurance_own_risk_storm" name="house_insurance_own_risk_storm"><option value="0" selected="selected">Afkopen</option><option value="1">Niet afkopen</option></select>
</div>
</div>
</div>
</div>
<div class="row product-coverages" data-product="1">
<hr>
<div class="panel-group float full-width mb5" id="accordion" role="tablist" aria-multiselectable="true">
<div class="panel panel-default">
<div class="panel-heading" role="tab" id="headingOne">
<h4 class="panel-title">
<a class="collapsed" role="button" data-toggle="collapse" data-parent="#accordion"
href="#collapse_coverages_1"
aria-expanded="false" aria-controls="collapse_coverages_1">
Klik hier voor de dekkingen per maatschappij
</a>
</h4>
</div>
<div id="collapse_coverages_1" class="panel-collapse collapse" role="tabpanel"
aria-labelledby="headingOne">
<div class="panel-body">
<table class="table product-coverages-table">
<thead>
<tr>
<td>Maatschappij</td>
<td>Dekking</td>
<td>Herbouwwaarde</td>
</tr>
</thead>
<tbody>
<tr data-company="1">
<td>
<label class="control-label text-left">Unigarant</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
readonly
data-company="1" autocomplete="off">
<option value="3" data-selected-initially="1"
data-default-score="4"
data-realname="Allrisk" selected>
Allrisk
</option>
</select>
</td>
<td>
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control api-fillable" readonly type="text"/>
</div>
</td>
</tr>
<tr data-company="2">
<td>
<label class="control-label text-left">Nationale Nederlanden</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
readonly
data-company="2" autocomplete="off">
<option value="3" data-selected-initially="1"
data-default-score="4"
data-realname="Allrisk" selected>
All-in
</option>
<option value="4" data-selected-initially="0"
data-default-score="3"
data-realname="Allrisk (maatwerk)" >
All-in (maatwerk)
</option>
</select>
</td>
<td>
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control api-fillable" readonly type="text"/>
</div>
</td>
</tr>
<tr data-company="3">
<td>
<label class="control-label text-left">a.s.r.</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
readonly
data-company="3" autocomplete="off">
<option value="3" data-selected-initially="1"
data-default-score="4"
data-realname="Allrisk" selected>
Allrisk
</option>
</select>
</td>
<td>
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control api-fillable" readonly type="text"/>
</div>
</td>
</tr>
<tr data-company="6">
<td>
<label class="control-label text-left">Reaal</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
readonly
data-company="6" autocomplete="off">
<option value="3" data-selected-initially="1"
data-default-score="4"
data-realname="Allrisk" selected>
Allrisk
</option>
</select>
</td>
<td>
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control api-fillable" readonly type="text"/>
</div>
</td>
</tr>
<tr data-company="7">
<td>
<label class="control-label text-left">Ansvar Idéa</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
readonly
data-company="7" autocomplete="off">
<option value="3" data-selected-initially="1"
data-default-score="4"
data-realname="Allrisk" selected>
AVBKOD
</option>
</select>
</td>
<td>
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control api-fillable" readonly type="text"/>
</div>
</td>
</tr>
<tr data-company="8">
<td>
<label class="control-label text-left">Klaverblad</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
readonly
data-company="8" autocomplete="off">
<option value="3" data-selected-initially="1"
data-default-score="4"
data-realname="Allrisk" selected>
Royaal
</option>
</select>
</td>
<td>
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control api-fillable" readonly type="text"/>
</div>
</td>
</tr>
<tr data-company="17">
<td>
<label class="control-label text-left">Turien en co.</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
readonly
data-company="17" autocomplete="off">
<option value="3" data-selected-initially="1"
data-default-score="4"
data-realname="Allrisk" selected>
Allrisk
</option>
<option value="103" data-selected-initially="0"
data-default-score="3"
data-realname="Allrisk (Premium)" >
Allrisk (Premium)
</option>
</select>
</td>
<td>
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control api-fillable" readonly type="text"/>
</div>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
</div>
</div> <div class="row product-risks-wrapper" data-product-id="1" data-product-name="Woonhuis"></div> </div>
</div>
<div class="panel panel-default">
<div class="panel-heading">Inboedel: Verzekerd bedrag per rubriek</div>
<div class="panel-body">
<div class="row modal-risk">
<div class="col-xs-12">
<div class="checkbox">
<label>
<input id="hogere-verzekerde-bedragen-rubrieken-checkbox" class="modal-risk-input" type="checkbox">
<span class="cr"><i class="cr-icon fa fa-check"></i></span>
<strong>Hogere verzekerde bedragen per rubriek opgeven</strong>
</label>
</div>
<hr/>
</div>
</div>
<div id="hogere-verzekerde-bedragen-rubrieken" class="row">
<div class="col-xs-12">
<h4>Klaverblad</h4>
<div class="form-group">
<div class="col-lg-8 col-md-8 col-xs-7">
<div>Is de totale waarde van de sieraden en horloges,
elektronische apparatuur, hobbygereedschap en andere bijzondere bezittingen,
zoals antiek, kunst en verzamelingen hoger dan € 30.000?
</div>
</div>
<div class="col-lg-4 col-md-4 col-xs-5">
<div class="form-group">
<div class="col-xs-12">
<select class="form-control" name="insured_amount_klaverblad_option"><option value="0" selected="selected">Nee</option><option value="1">Ja</option></select>
</div>
</div>
<div class="form-group">
<div class="col-xs-12">
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control" name="insured_amount_klaverblad_value" type="number">
</div>
</div>
</div>
</div>
<div class="col-xs-12">
<small>Let op: Een hoger verzekerd bedrag moet telefonisch besproken worden met
Klaverblad, en kan dus niet door CompanyName berekend worden.
</small>
</div>
</div>
<h4>ASR</h4>
<div class="form-group">
<div class="col-lg-8 col-md-8 col-xs-7">
<div>Is de totale waarde van bijzondere bezittingen hoger dan
€ 15.000?
</div>
<small>Bijzondere bezittingen: uw kunst, verzamelingen, antiek, foto-, film-,
beeld-, audio- en videoapparatuur en beeld- en geluidsdragers, computers,
muziekinstrumenten, duiksport-, paardensport-, paracture-, gold- en
hengelsportuitrustingen en medische apparatuur (gehoorapparaten vallen hier
niet onder). Uw mobiele elektronica valt niet onder bijzondere bezittingen.
</small>
<br/><br/>
</div>
<div class="col-lg-4 col-md-4 col-xs-5">
<div class="form-group">
<div class="col-xs-12">
<select class="form-control" name="insured_amount_asr_option"><option value="0" selected="selected">Nee</option><option value="1">Ja</option></select>
</div>
</div>
<div class="form-group">
<div class="col-xs-12">
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control" name="insured_amount_asr_value" type="number">
</div>
</div>
</div>
</div>
<div class="col-xs-12">
<small>Let op: Een totale waarde van € 50.000 moet telefonisch besproken worden
met a.s.r., en kan dus niet door CompanyName berekend worden.
</small>
</div>
</div>
<h4>Eventuele bijtellingen
<small>voorzover niet apart verzekerd</small>
</h4>
<div class="form-group">
<div class="col-lg-8 col-md-8 col-xs-7">
<div>Heeft u meer dan € 12.000 aan audiovisuele- en computerapparatuur?</div>
<br/>
<div>Zo ja, welk bedrag boven € 12.000?</div>
</div>
<div class="col-lg-4 col-md-4 col-xs-5">
<div class="form-group">
<div class="col-xs-12">
<select class="form-control" name="insured_amount_audiovisual_option"><option value="0" selected="selected">Nee</option><option value="1">Ja</option></select>
</div>
</div>
<div class="form-group">
<div class="col-xs-12">
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control" name="insured_amount_audiovisual_value" type="number">
</div>
</div>
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-8 col-md-8 col-xs-7">
<div>Heeft u meer dan € 6.000 aan lijfsieraden?</div>
<br/>
<div>Zo ja, welk bedrag boven € 6.000?</div>
</div>
<div class="col-lg-4 col-md-4 col-xs-5">
<div class="form-group">
<div class="col-xs-12">
<select class="form-control" name="insured_amount_jewelry_option"><option value="0" selected="selected">Nee</option><option value="1">Ja</option></select>
</div>
</div>
<div class="form-group">
<div class="col-xs-12">
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control" name="insured_amount_jewelry_value" type="number">
</div>
</div>
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-8 col-md-8 col-xs-7">
<div>Heeft u meer dan € 15.000 aan bijzondere bezittingen?</div>
<br/>
<div>Zo ja, welk bedrag boven € 15.000?</div>
</div>
<div class="col-lg-4 col-md-4 col-xs-5">
<div class="form-group">
<div class="col-xs-12">
<select class="form-control" name="insured_amount_special_possessions_option"><option value="0" selected="selected">Nee</option><option value="1">Ja</option></select>
</div>
</div>
<div class="form-group">
<div class="col-xs-12">
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control" name="insured_amount_special_possessions_value" type="number">
</div>
</div>
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-8 col-md-8 col-xs-7">
<div>Heeft u meer dan € 6.000 aan huurdersbelang?</div>
<br/>
<div>Zo ja, welk bedrag boven € 6.000?</div>
</div>
<div class="col-lg-4 col-md-4 col-xs-5">
<div class="form-group">
<div class="col-xs-12">
<select class="form-control" name="insured_amount_renter_stake_option"><option value="0" selected="selected">Nee</option><option value="1">Ja</option></select>
</div>
</div>
<div class="form-group">
<div class="col-xs-12">
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control" name="insured_amount_renter_stake_value" type="number">
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="col-lg-6 col-md-6 col-sm-12 col-xs-12">
<div class="panel panel-default">
<div class="panel-heading">Risico's en voorwaarden inboedel</div>
<div class="panel-body inputinlabel">
<div class="row">
<div class="col-xs-12">
<input type="hidden" name="furniture_insurance_start_date"
value="28-03-2018"/>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<button type="button" class="btn btn-default btn-xs pull-right ml5" data-toggle="modal"
data-target="#inventory-own-risk-modal"><i class="fa fa-info-circle"></i></button>
<label for="furniture_insurance_own_risk" class="control-label">Eigen risico's</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="furniture_insurance_own_risk" name="furniture_insurance_own_risk"><option value="geen-eigen-risico-of-zo-laag-mogelijk" selected="selected">Geen eigen risico of zo laag mogelijk</option><option value="met-eigen-risico-maar-zo-laag-mogelijk">Met eigen risico, maar zo laag mogelijk</option><option value="met-eigen-risico-maar-zo-hoog-mogelijk">Met eigen risico, maar zo hoog mogelijk</option></select>
</div>
</div>
</div>
</div>
<div class="row product-coverages" data-product="3">
<hr>
<div class="panel-group float full-width mb5" id="accordion" role="tablist" aria-multiselectable="true">
<div class="panel panel-default">
<div class="panel-heading" role="tab" id="headingOne">
<h4 class="panel-title">
<a class="collapsed" role="button" data-toggle="collapse" data-parent="#accordion"
href="#collapse_coverages_3"
aria-expanded="false" aria-controls="collapse_coverages_3">
Klik hier voor de dekkingen per maatschappij
</a>
</h4>
</div>
<div id="collapse_coverages_3" class="panel-collapse collapse" role="tabpanel"
aria-labelledby="headingOne">
<div class="panel-body">
<table class="table product-coverages-table">
<thead>
<tr>
<td>Maatschappij</td>
<td>Dekking</td>
<td>Inboedelwaarde</td>
</tr>
</thead>
<tbody>
<tr data-company="1">
<td>
<label class="control-label text-left">Unigarant</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="1" autocomplete="off">
<option value="9" data-selected-initially="0"
data-default-score="4"
data-realname="Allrisk" >
Allrisk
</option>
<option value="60" data-selected-initially="1"
data-default-score="2"
data-realname="Allrisk + Smartphone & Tablet" selected>
Allrisk + Smartphone & Tablet
</option>
<option value="61" data-selected-initially="0"
data-default-score="2"
data-realname="Allrisk + Buitenshuis" >
Allrisk + Buitenshuis
</option>
<option value="62" data-selected-initially="0"
data-default-score="1"
data-realname="Allrisk + Smartphone & Tablet + Buitenshuis" >
Allrisk + Smartphone & Tablet + Buitenshuis
</option>
</select>
</td>
<td>
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control api-fillable" readonly type="text"/>
</div>
</td>
</tr>
<tr data-company="2">
<td>
<label class="control-label text-left">Nationale Nederlanden</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="2" autocomplete="off">
<option value="9" data-selected-initially="0"
data-default-score="4"
data-realname="Allrisk" >
All-in
</option>
<option value="14" data-selected-initially="0"
data-default-score="3"
data-realname="Allrisk (maatwerk)" >
All-in (maatwerk)
</option>
<option value="61" data-selected-initially="0"
data-default-score="2"
data-realname="Allrisk + Buitenshuis" >
Allrisk + Buitenshuis
</option>
<option value="88" data-selected-initially="1"
data-default-score="0"
data-realname="Allrisk + Buitenshuis (Maatwerk)" selected>
Allrisk + Buitenshuis (Maatwerk)
</option>
</select>
</td>
<td>
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control api-fillable" readonly type="text"/>
</div>
</td>
</tr>
<tr data-company="3">
<td>
<label class="control-label text-left">a.s.r.</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="3" autocomplete="off">
<option value="9" data-selected-initially="0"
data-default-score="4"
data-realname="Allrisk" >
Allrisk
</option>
<option value="72" data-selected-initially="1"
data-default-score="2"
data-realname="Allrisk + Mobiele elektronica" selected>
Allrisk + Mobiele elektronica
</option>
<option value="73" data-selected-initially="0"
data-default-score="2"
data-realname="Allrisk + Kostbaarheden" >
Allrisk + Kostbaarheden
</option>
<option value="74" data-selected-initially="0"
data-default-score="1"
data-realname="Allrisk + Mobiele elektronica + Kostbaarheden" >
Allrisk + Mobiele elektronica + Kostbaarheden
</option>
</select>
</td>
<td>
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control api-fillable" readonly type="text"/>
</div>
</td>
</tr>
<tr data-company="6">
<td>
<label class="control-label text-left">Reaal</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="6" autocomplete="off">
<option value="9" data-selected-initially="1"
data-default-score="4"
data-realname="Allrisk" selected>
Allrisk
</option>
<option value="61" data-selected-initially="0"
data-default-score="2"
data-realname="Allrisk + Buitenshuis" >
Allrisk + Buitenshuis
</option>
</select>
</td>
<td>
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control api-fillable" readonly type="text"/>
</div>
</td>
</tr>
<tr data-company="7">
<td>
<label class="control-label text-left">Ansvar Idéa</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="7" autocomplete="off">
<option value="9" data-selected-initially="1"
data-default-score="4"
data-realname="Allrisk" selected>
AVBKOD
</option>
</select>
</td>
<td>
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control api-fillable" readonly type="text"/>
</div>
</td>
</tr>
<tr data-company="8">
<td>
<label class="control-label text-left">Klaverblad</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="8" autocomplete="off">
<option value="9" data-selected-initially="1"
data-default-score="4"
data-realname="Allrisk" selected>
Royaal
</option>
</select>
</td>
<td>
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control api-fillable" readonly type="text"/>
</div>
</td>
</tr>
<tr data-company="17">
<td>
<label class="control-label text-left">Turien en co.</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="17" autocomplete="off">
<option value="9" data-selected-initially="1"
data-default-score="4"
data-realname="Allrisk" selected>
Allrisk
</option>
<option value="104" data-selected-initially="0"
data-default-score="4"
data-realname="Allrisk (Premium)" >
Allrisk (Premium)
</option>
</select>
</td>
<td>
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control api-fillable" readonly type="text"/>
</div>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
</div>
</div> <div class="row product-risks-wrapper" data-product-id="3" data-product-name="Inboedel"></div> </div>
</div>
<div class="panel panel-default">
<div class="panel-heading">Risico's en voorwaarden buitenshuis</div>
<div class="panel-body">
<div class="row hidden-">
<div class="col-xs-12">
<input type="hidden" name="outside_coverage_start_date"
value="28-03-2018"/>
<div class="row product-coverages" data-product="4">
<hr>
<div class="panel-group float full-width mb5" id="accordion" role="tablist" aria-multiselectable="true">
<div class="panel panel-default">
<div class="panel-heading" role="tab" id="headingOne">
<h4 class="panel-title">
<a class="collapsed" role="button" data-toggle="collapse" data-parent="#accordion"
href="#collapse_coverages_4"
aria-expanded="false" aria-controls="collapse_coverages_4">
Klik hier voor de dekkingen per maatschappij
</a>
</h4>
</div>
<div id="collapse_coverages_4" class="panel-collapse collapse" role="tabpanel"
aria-labelledby="headingOne">
<div class="panel-body">
<table class="table product-coverages-table">
<thead>
<tr>
<td>Maatschappij</td>
<td>Dekking</td>
</tr>
</thead>
<tbody>
<tr data-company="1">
<td>
<label class="control-label text-left">Unigarant</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="1" autocomplete="off">
<option value="48" data-selected-initially="0"
data-default-score="1"
data-realname="Buitenshuisdekking" >
Buitenshuisdekking
</option>
<option value="90" data-selected-initially="0"
data-default-score="3"
data-realname="Allrisk" >
Allrisk
</option>
<option value="93" data-selected-initially="0"
data-default-score="2"
data-realname="Allrisk + Buitenshuis" >
Allrisk + Buitenshuis
</option>
<option value="97" data-selected-initially="1"
data-default-score="2"
data-realname="Allrisk + Smartphone & Tablet" selected>
Allrisk + Smartphone & Tablet
</option>
<option value="98" data-selected-initially="0"
data-default-score="1"
data-realname="Allrisk + Smartphone & Tablet + Buitenshuis" >
Allrisk + Smartphone & Tablet + Buitenshuis
</option>
</select>
</td>
</tr>
<tr data-company="2">
<td>
<label class="control-label text-left">Nationale Nederlanden</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="2" autocomplete="off">
<option value="48" data-selected-initially="0"
data-default-score="1"
data-realname="Buitenshuisdekking" >
Buitenshuisdekking
</option>
<option value="90" data-selected-initially="0"
data-default-score="3"
data-realname="Allrisk" >
All-in
</option>
<option value="91" data-selected-initially="0"
data-default-score="3"
data-realname="Allrisk (maatwerk)" >
All-in (maatwerk)
</option>
<option value="92" data-selected-initially="0"
data-default-score="4"
data-realname="Allrisk (standaard)" >
All-in (standaard)
</option>
<option value="93" data-selected-initially="0"
data-default-score="2"
data-realname="Allrisk + Buitenshuis" >
Allrisk + Buitenshuis
</option>
<option value="99" data-selected-initially="0"
data-default-score="0"
data-realname="Allrisk + Buitenshuis (Maatwerk)" >
Allrisk + Buitenshuis (Maatwerk)
</option>
<option value="100" data-selected-initially="1"
data-default-score="2"
data-realname="Allrisk + Buitenshuis (Standaard)" selected>
Allrisk + Buitenshuis (Standaard)
</option>
</select>
</td>
</tr>
<tr data-company="3">
<td>
<label class="control-label text-left">a.s.r.</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="3" autocomplete="off">
<option value="48" data-selected-initially="0"
data-default-score="1"
data-realname="Buitenshuisdekking" >
Buitenshuisdekking
</option>
<option value="90" data-selected-initially="0"
data-default-score="3"
data-realname="Allrisk" >
Allrisk
</option>
<option value="94" data-selected-initially="1"
data-default-score="2"
data-realname="Allrisk + Mobiele elektronica" selected>
Allrisk + Mobiele elektronica
</option>
<option value="95" data-selected-initially="0"
data-default-score="2"
data-realname="Allrisk + Kostbaarheden" >
Allrisk + Kostbaarheden
</option>
<option value="96" data-selected-initially="0"
data-default-score="1"
data-realname="Allrisk + Mobiele elektronica + Kostbaarheden" >
Allrisk + Mobiele elektronica + Kostbaarheden
</option>
</select>
</td>
</tr>
<tr data-company="6">
<td>
<label class="control-label text-left">Reaal</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="6" autocomplete="off">
<option value="48" data-selected-initially="0"
data-default-score="1"
data-realname="Buitenshuisdekking" >
Buitenshuisdekking
</option>
<option value="90" data-selected-initially="1"
data-default-score="3"
data-realname="Allrisk" selected>
Allrisk
</option>
<option value="93" data-selected-initially="0"
data-default-score="2"
data-realname="Allrisk + Buitenshuis" >
Allrisk + Buitenshuis
</option>
</select>
</td>
</tr>
<tr data-company="7">
<td>
<label class="control-label text-left">Ansvar Idéa</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="7" autocomplete="off">
<option value="48" data-selected-initially="0"
data-default-score="1"
data-realname="Buitenshuisdekking" >
Buitenshuisdekking
</option>
<option value="90" data-selected-initially="1"
data-default-score="3"
data-realname="Allrisk" selected>
AVBKOD
</option>
</select>
</td>
</tr>
<tr data-company="8">
<td>
<label class="control-label text-left">Klaverblad</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="8" autocomplete="off">
<option value="48" data-selected-initially="0"
data-default-score="1"
data-realname="Buitenshuisdekking" >
Buitenshuisdekking
</option>
<option value="90" data-selected-initially="1"
data-default-score="3"
data-realname="Allrisk" selected>
Royaal
</option>
</select>
</td>
</tr>
<tr data-company="17">
<td>
<label class="control-label text-left">Turien en co.</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="17" autocomplete="off">
</select>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
</div>
</div> <div class="row product-risks-wrapper" data-product-id="4" data-product-name="Buitenshuisdekking"></div> </div>
</div>
</div>
</div>
</form>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div role="tabpanel" class="tab-pane" id="tab-car">
<div class="row tp-wrapper">
<div class="col-sm-12">
<form method="POST" action="https://app.example.net/app/car/store" accept-charset="UTF-8" class="form-horizontal"><input name="_token" type="hidden" value="LSJ7UMmOiFRd1ufN0UBhb4WuSKg907ZGCfXiwIym">
<div class="row">
<div class="col-lg-7 col-md-7 col-sm-12 col-xs-12">
<div class="panel panel-default">
<div class="panel-heading pull-left col-xs-12">
<div class="pull-left">Autogegevens</div>
</div>
<div class="panel-body">
<p></p>
<br/>
<div class="row">
<div class="col-lg-5 col-md-5 col-sm-12 col-xs-12">
<input type="hidden" name="start_date" value="28-03-2018"/>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="license_plate" class="control-label">Kenteken</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control required" name="license_plate" type="text" value="34grt2" id="license_plate">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="model_code" class="control-label">Meldcode</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control api-fillable" name="model_code" type="text" value="6660" id="model_code">
</div>
</div>
<input type="hidden" name="cilinder_contents" value="0"/>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-12">
<label for="manufacture_year" class="control-label">Bouwjaar en -maand</label>
</div>
<div class="col-lg-5 col-md-5 col-xs-7">
<input class="form-control api-fillable" placeholder="jjjj" name="manufacture_year" type="text" value="2008" id="manufacture_year">
</div>
<div class="col-lg-3 col-md-3 col-xs-5">
<input class="form-control" placeholder="mm" name="manufacture_month" type="text" value="0">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="new_value" class="control-label">Nieuwwaarde</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control api-fillable" name="new_value" type="text" value="16553" id="new_value">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="day_value" class="control-label">Dagwaarde</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control" name="day_value" type="text" id="day_value">
</div>
</div>
</div>
</div>
<div class="col-lg-7 col-md-7 col-sm-12 col-xs-12">
<div class="form-group">
<div class="col-lg-3 col-md-3 col-xs-5">
<label for="brand" class="control-label">Merk</label>
</div>
<div class="col-lg-9 col-md-9 col-xs-7">
<input class="form-control api-fillable" name="brand" type="text" value="HONDA" id="brand">
</div>
</div>
<div class="form-group">
<div class="col-lg-3 col-md-3 col-xs-5">
<label for="model" class="control-label">Model</label>
</div>
<div class="col-lg-9 col-md-9 col-xs-7">
<input class="form-control api-fillable" name="model" type="text" value="Jazz" id="model">
</div>
</div>
<div class="form-group">
<div class="col-lg-3 col-md-3 col-xs-5">
<label for="type" class="control-label">Type</label>
</div>
<div class="col-lg-9 col-md-9 col-xs-7">
<input class="form-control api-fillable" name="type" type="text" value="1.4 I" id="type">
</div>
</div>
<div class="form-group">
<div class="col-lg-3 col-md-3 col-xs-5">
<label for="body" class="control-label">Carrosserie</label>
</div>
<div class="col-lg-9 col-md-9 col-xs-7">
<input class="form-control api-fillable" name="body" type="text" value="Hatchback" id="body">
</div>
</div>
<div class="form-group">
<div class="col-lg-3 col-md-3 col-xs-5">
<label for="weight" class="control-label">Gewicht</label>
</div>
<div class="col-lg-9 col-md-9 col-xs-7">
<div class="input-group">
<div class="input-group-addon">KG</div>
<input class="form-control api-fillable" name="weight" type="text" value="971" id="weight">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-3 col-md-3 col-xs-5">
<label for="fuel_code" class="control-label">Brandstof</label>
</div>
<div class="col-lg-9 col-md-9 col-xs-7">
<select class="form-control api-fillable" id="fuel_code" name="fuel_code"><option value="A">Alcohol</option><option value="B" selected="selected">Benzine</option><option value="C">Cryogeen</option><option value="D">Diesel</option><option value="E">Electrisch</option><option value="BE">Hybride benzine</option><option value="DE">Hybride diesel</option><option value="G">Gas (LPG / Propaan)</option><option value="H">Hogedruk gas</option><option value="W">Waterstof</option></select>
</div>
</div>
</div>
</div>
<div class="row klaverblad-options-row hidden">
<div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
<hr/>
<div class="alert alert-warning" role="alert">U moet handmatig de volgende gegevens aanvullen om auto Klaverblad te berekenen.</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="klaverblad_model" class="control-label">Model voor Klaverblad</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control api-fillable" id="klaverblad_model" name="klaverblad_model"></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="klaverblad_body" class="control-label">Carrosserie voor Klaverblad</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control api-fillable" id="klaverblad_body" name="klaverblad_body"></select>
</div>
</div>
</div>
</div>
<div class="row">
<div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
<hr/>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="incl_vat" class="control-label">Incl. BTW</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="incl_vat" name="incl_vat"><option value="ja" selected="selected">Ja</option><option value="nee">Nee</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="private_usage" class="control-label">Particulier gebruik</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="private_usage" name="private_usage"><option value="ja" selected="selected">Ja</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="financed" class="control-label">Is het voertuig gefinancierd</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="financed" name="financed"><option value="nee" selected="selected">Nee</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="imported" class="control-label">Voertuig geïmporteerd</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="imported" name="imported"><option value="nee" selected="selected">Nee</option><option value="ja">Ja</option></select>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="col-lg-5 col-md-5 col-sm-12 col-xs-12">
<div class="panel panel-default">
<div class="panel-heading">Voertuig 1</div>
<div class="panel-body">
<div class="row">
<div class="col-xs-12">
<img class="full-size" src="https://app.example.net/img/car.jpg">
</div>
</div>
<div class="row">
<div class="col-xs-12">
<br/>
<span class="streetview-street"></span> <span class="streetview-housenumber"></span><br/>
<span class="streetview-postalcode"></span> <span class="streetview-city"></span><br/>
<span class="streetview-family-situation"></span>
<hr/>
</div>
</div>
<div class="row form-color-legend"></div> </div>
</div>
</div>
</div>
<div class="row">
<div class="col-lg-7 col-md-7 col-sm-12 col-xs-12">
<div class="panel panel-default">
<div class="panel-heading">Dekking</div>
<div class="panel-body">
<div class="row">
<div class="col-xs-12">
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_claim_free_years" class="control-label">Schadevrije jaren</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="main_driver_claim_free_years" name="main_driver_claim_free_years"><option value="-6">-6</option><option value="-5">-5</option><option value="-4">-4</option><option value="-3">-3</option><option value="-2">-2</option><option value="-1">-1</option><option value="0" selected="selected">0</option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="8">8</option><option value="9">9</option><option value="10">10</option><option value="11">11</option><option value="12">12</option><option value="13">13</option><option value="14">14</option><option value="15">15</option><option value="16">16</option><option value="17">17</option><option value="18">18</option><option value="19">19</option><option value="20">20</option><option value="21">21</option><option value="22">22</option><option value="23">23</option><option value="24">24</option><option value="25">25</option><option value="26">26</option><option value="27">27</option><option value="28">28</option><option value="29">29</option><option value="30">30</option><option value="31">31</option><option value="32">32</option><option value="33">33</option><option value="34">34</option><option value="35">35</option><option value="36">36</option><option value="37">37</option><option value="38">38</option><option value="39">39</option><option value="40">40</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="coverage" class="control-label">Dekking</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7 inputinlabel">
<input id="coverage_wa" name="coverage" type="radio" value="wa">
<label for="coverage_wa" class="control-label">WA</label>
<input id="coverage_beperkt-casco" name="coverage" type="radio" value="beperkt-casco">
<label for="coverage_beperkt-casco" class="control-label">Beperkt casco</label>
<input id="coverage_volledig-casco" checked="checked" name="coverage" type="radio" value="volledig-casco">
<label for="coverage_volledig-casco" class="control-label">Volledig casco</label>
<input id="coverage_verschillend-per-maatschappij" name="coverage" type="radio" value="verschillend-per-maatschappij">
<label for="coverage_verschillend-per-maatschappij" class="control-label">Verschillend per maatschappij</label>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="mileage" class="control-label">Kilometrage</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon">km</div>
<input class="form-control" name="mileage" type="number" value="12000" id="mileage">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="accessories_insured" class="control-label">Accessoires meeverzekeren?</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control" name="accessories_insured" type="number" value="0" id="accessories_insured">
</div>
</div>
</div>
<div id="vehicle-own-risk-fields">
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="own_risk_ahb" class="control-label">Eigen risico</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="own_risk_ahb" name="own_risk_ahb"><option value="geen-eigen-risico-of-zo-laag-mogelijk" selected="selected">Geen eigen risico of zo laag mogelijk</option><option value="met-eigen-risico-maar-zo-laag-mogelijk">Met eigen risico, maar zo laag mogelijk</option><option value="met-eigen-risico-maar-zo-hoog-mogelijk">Met eigen risico, maar zo hoog mogelijk</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="own_risk_non_ahb" class="control-label">Vrijwillig eigen risico</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="own_risk_non_ahb" name="own_risk_non_ahb"><option value="geen-eigen-risico-of-zo-laag-mogelijk" selected="selected">Geen eigen risico of zo laag mogelijk</option><option value="met-eigen-risico-maar-zo-laag-mogelijk">Met eigen risico, maar zo laag mogelijk</option><option value="met-eigen-risico-maar-zo-hoog-mogelijk">Met eigen risico, maar zo hoog mogelijk</option></select>
</div>
</div>
</div>
<hr/>
<div class="row">
<div class="col-lg-4 col-md-4 col-xs-5">
<h4>Aanvullende dekkingen</h4>
</div>
</div>
<div class="row">
<div class="col-sm-6 col-xs-12 mb5">
<div class="float full-size">
<label for="avd_accidents_passengers" class="control-label">Ongevallen inzittenden</label>
</div>
<div class="float full-size">
<select class="form-control" id="avd_accidents_passengers" name="avd_accidents_passengers"><option value="geen-dekking">Geen dekking</option><option value="standaard-verzekerde-bedragen">Standaard verzekerde bedragen</option><option value="lage-verzekerde-bedragen">Lage verzekerde bedragen</option><option value="hoge-verzekerde-bedragen">Hoge verzekerde bedragen</option></select>
</div>
</div>
<div class="col-sm-6 col-xs-12 mb5">
<div class="float full-size">
<label for="avd_damage_insured_passengers" class="control-label">Schadeverzekering voor inzittenden</label>
</div>
<div class="float full-size">
<select class="form-control" id="avd_damage_insured_passengers" name="avd_damage_insured_passengers"><option value="geen-dekking">Geen dekking</option><option value="basis">Basis</option><option value="uitgebreide-dekking-vsv">Uitgebreide dekking (VSV)</option></select>
</div>
</div>
<div class="col-sm-6 col-xs-12 mb5">
<div class="float full-size">
<label for="avd_claim_or_legal_aid" class="control-label">Verhaalshulp of rechtsbijstand</label>
</div>
<div class="float full-size">
<select class="form-control" id="avd_claim_or_legal_aid" name="avd_claim_or_legal_aid"><option value="geen-dekking">Geen dekking</option><option value="verhaalshulp">Verhaalshulp</option><option value="rechtsbijstand">Rechtsbijstand</option><option value="rechtsbijstand-uitgebreid">Rechtsbijstand uitgebreid</option></select>
</div>
</div>
<div class="col-sm-6 col-xs-12 mb5">
<div class="float full-size">
<label for="avd_breakdown_service_cover_area" class="control-label">Pechhulp NL of EU</label>
</div>
<div class="float full-size">
<select class="form-control" id="avd_breakdown_service_cover_area" name="avd_breakdown_service_cover_area"><option value="geen-dekking">Geen dekking</option><option value="nederland">Nederland</option><option value="europe">Europe</option></select>
</div>
</div>
<div class="col-sm-6 col-xs-12 mb5">
<div class="float full-size">
<label for="purchase_value_insured_period" class="control-label">Aanschafwaarderegeling of -garantie</label>
</div>
<div class="float full-size">
<select class="form-control" id="purchase_value_insured_period" name="purchase_value_insured_period"><option value="nee" selected="selected">Nee</option><option value="aankoopwaarde1jaar">1 jaar</option><option value="aankoopwaarde2jaar">2 jaar</option><option value="aankoopwaarde3jaar">3 jaar</option></select>
</div>
</div>
<div class="col-sm-6 col-xs-12 mb5">
<div class="float full-size">
<label for="new_value_insured_period" class="control-label">Nieuwwaarderegeling of -garantie</label>
</div>
<div class="float full-size">
<select class="form-control" id="new_value_insured_period" name="new_value_insured_period"><option value="nee" selected="selected">Nee</option><option value="standaard1jaar">1 jaar</option><option value="nieuwwaarde2jaar">2 jaar</option><option value="nieuwwaarde3jaar">3 jaar</option></select>
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel mb5 id-extended_coverages_no-claimbeschermer">
<input id="extended_coverages_no-claimbeschermer" name="extended_coverages[]" type="checkbox" value="no-claimbeschermer">
<label for="extended_coverages_no-claimbeschermer" class="control-label">No-claimbeschermer</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel mb5 id-extended_coverages_vervangend-vervoer">
<input id="extended_coverages_vervangend-vervoer" name="extended_coverages[]" type="checkbox" value="vervangend-vervoer">
<label for="extended_coverages_vervangend-vervoer" class="control-label">Vervangend vervoer</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel mb5 id-extended_coverages_geen-eigen-risico-bij-niet-aangesloten-herstelbedrijf-vrije-keuze">
<input id="extended_coverages_geen-eigen-risico-bij-niet-aangesloten-herstelbedrijf-vrije-keuze" name="extended_coverages[]" type="checkbox" value="geen-eigen-risico-bij-niet-aangesloten-herstelbedrijf-vrije-keuze">
<label for="extended_coverages_geen-eigen-risico-bij-niet-aangesloten-herstelbedrijf-vrije-keuze" class="control-label">Geen eigen risico bij niet-aangesloten herstelbedrijf (Vrije keuze)</label>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="panel panel-default">
<div class="panel-heading">Risico's en voorwaarden auto</div>
<div class="panel-body">
<div class="row product-coverages" data-product="9">
<hr>
<div class="panel-group float full-width mb5" id="accordion" role="tablist" aria-multiselectable="true">
<div class="panel panel-default">
<div class="panel-heading" role="tab" id="headingOne">
<h4 class="panel-title">
<a class="collapsed" role="button" data-toggle="collapse" data-parent="#accordion"
href="#collapse_coverages_9"
aria-expanded="false" aria-controls="collapse_coverages_9">
Klik hier voor de dekkingen per maatschappij
</a>
</h4>
</div>
<div id="collapse_coverages_9" class="panel-collapse collapse" role="tabpanel"
aria-labelledby="headingOne">
<div class="panel-body">
<table class="table product-coverages-table">
<thead>
<tr>
<td>Maatschappij</td>
<td>Dekking</td>
</tr>
</thead>
<tbody>
<tr data-company="1">
<td>
<label class="control-label text-left">Unigarant</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="1" autocomplete="off">
<option value="55" data-selected-initially="1"
data-default-score="1"
data-realname="WA" selected>
WA
</option>
<option value="56" data-selected-initially="0"
data-default-score="1"
data-realname="Beperkt casco" >
Beperkt casco
</option>
<option value="57" data-selected-initially="0"
data-default-score="1"
data-realname="Volledig casco" >
Volledig casco
</option>
</select>
</td>
</tr>
<tr data-company="2">
<td>
<label class="control-label text-left">Nationale Nederlanden</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="2" autocomplete="off">
<option value="55" data-selected-initially="1"
data-default-score="1"
data-realname="WA" selected>
WA
</option>
<option value="56" data-selected-initially="0"
data-default-score="1"
data-realname="Beperkt casco" >
Beperkt casco
</option>
<option value="57" data-selected-initially="0"
data-default-score="1"
data-realname="Volledig casco" >
Volledig casco
</option>
</select>
</td>
</tr>
<tr data-company="3">
<td>
<label class="control-label text-left">a.s.r.</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="3" autocomplete="off">
<option value="55" data-selected-initially="1"
data-default-score="1"
data-realname="WA" selected>
WA
</option>
<option value="56" data-selected-initially="0"
data-default-score="1"
data-realname="Beperkt casco" >
Beperkt casco
</option>
<option value="57" data-selected-initially="0"
data-default-score="1"
data-realname="Volledig casco" >
Volledig casco
</option>
<option value="58" data-selected-initially="0"
data-default-score="1"
data-realname="Inruilplus (a.s.r.)" >
Inruilplus (a.s.r.)
</option>
</select>
</td>
</tr>
<tr data-company="6">
<td>
<label class="control-label text-left">Reaal</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="6" autocomplete="off">
<option value="55" data-selected-initially="1"
data-default-score="1"
data-realname="WA" selected>
WA
</option>
<option value="56" data-selected-initially="0"
data-default-score="1"
data-realname="Beperkt casco" >
Beperkt casco
</option>
<option value="57" data-selected-initially="0"
data-default-score="1"
data-realname="Volledig casco" >
Volledig casco
</option>
</select>
</td>
</tr>
<tr data-company="7">
<td>
<label class="control-label text-left">Ansvar Idéa</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="7" autocomplete="off">
<option value="55" data-selected-initially="1"
data-default-score="1"
data-realname="WA" selected>
WA
</option>
<option value="56" data-selected-initially="0"
data-default-score="1"
data-realname="Beperkt casco" >
Beperkt casco
</option>
<option value="57" data-selected-initially="0"
data-default-score="1"
data-realname="Volledig casco" >
Volledig casco
</option>
</select>
</td>
</tr>
<tr data-company="8">
<td>
<label class="control-label text-left">Klaverblad</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="8" autocomplete="off">
<option value="55" data-selected-initially="1"
data-default-score="1"
data-realname="WA" selected>
WA
</option>
<option value="56" data-selected-initially="0"
data-default-score="1"
data-realname="Beperkt casco" >
Beperkt casco
</option>
<option value="57" data-selected-initially="0"
data-default-score="1"
data-realname="Volledig casco" >
Volledig casco
</option>
</select>
</td>
</tr>
<tr data-company="17">
<td>
<label class="control-label text-left">Turien en co.</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="17" autocomplete="off">
<option value="55" data-selected-initially="1"
data-default-score="1"
data-realname="WA" selected>
WA
</option>
<option value="56" data-selected-initially="0"
data-default-score="1"
data-realname="Beperkt casco" >
Beperkt casco
</option>
<option value="57" data-selected-initially="0"
data-default-score="1"
data-realname="Volledig casco" >
Volledig casco
</option>
</select>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
</div>
</div> <div class="row product-risks-wrapper" data-product-id="9" data-product-name="Auto"></div> </div>
</div>
</div>
<div class="col-lg-5 col-md-5 col-sm-12 col-xs-12">
<div class="panel panel-default">
<div class="panel-heading">Regelmatige bestuurder</div>
<div class="panel-body">
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_insurer_is_main_driver" class="control-label">Verzekeringnemer is regelmatige bestuurder</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input id="main_driver_insurer_is_main_driver_ja" name="main_driver_insurer_is_main_driver" type="radio" value="ja">
<label for="main_driver_insurer_is_main_driver_ja" class="control-label">ja</label>
<input id="main_driver_insurer_is_main_driver_nee" name="main_driver_insurer_is_main_driver" type="radio" value="nee">
<label for="main_driver_insurer_is_main_driver_nee" class="control-label">nee</label>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_person" class="control-label">Wie is regelmatige bestuurder</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input id="main_driver_person_partner" name="main_driver_person" type="radio" value="partner">
<label for="main_driver_person_partner" class="control-label">Partner</label>
<input id="main_driver_person_anders" name="main_driver_person" type="radio" value="anders">
<label for="main_driver_person_anders" class="control-label">Anders</label>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_birthdate" class="control-label">Geboortedatum</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon"><i class="fa fa-calendar"></i></div>
<input class="form-control" placeholder="dd-mm-jjjj" name="main_driver_birthdate" type="text" value="09-05-1988" id="main_driver_birthdate">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_gender" class="control-label">Geslacht</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input id="main_driver_gender_man" name="main_driver_gender" type="radio" value="man">
<label for="main_driver_gender_man" class="control-label">Man</label>
<input id="main_driver_gender_vrouw" name="main_driver_gender" type="radio" value="vrouw">
<label for="main_driver_gender_vrouw" class="control-label">Vrouw</label>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_postcode" class="control-label">Postcode</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control required" name="main_driver_postcode" type="text" value="7908NV" id="main_driver_postcode">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_housenumber" class="control-label">Huisnummer</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control" name="main_driver_housenumber" type="text" value="3" id="main_driver_housenumber">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_street" class="control-label">Straat</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control" name="main_driver_street" type="text" id="main_driver_street">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_city" class="control-label">Woonplaats</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control" name="main_driver_city" type="text" id="main_driver_city">
</div>
</div>
</div>
</div>
</div>
</div>
</form>
</div>
</div> </div>
<div role="tabpanel" class="tab-pane" id="tab-car-oldtimer">
<div class="row tp-wrapper">
<div class="col-sm-12">
<form method="POST" action="https://app.example.net/app/car-oldtimer/store" accept-charset="UTF-8" class="form-horizontal"><input name="_token" type="hidden" value="LSJ7UMmOiFRd1ufN0UBhb4WuSKg907ZGCfXiwIym">
<div class="row">
<div class="col-lg-6 col-md-6 col-sm-12 col-xs-12">
<div class="panel panel-default">
<div class="panel-heading pull-left col-xs-12">
<div class="pull-left">Oldtimer autogegevens</div>
</div>
<div class="panel-body">
<p></p>
<br/>
<div class="row">
<div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
<input type="hidden" name="start_date" value="28-03-2018"/>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="license_plate" class="control-label">Kenteken</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control required" name="license_plate" type="text" id="license_plate">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="model_code" class="control-label">Meldcode</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control api-fillable" name="model_code" type="text" id="model_code">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="brand" class="control-label">Merk</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control api-fillable" name="brand" type="text" id="brand">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="model" class="control-label">Model</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control api-fillable" name="model" type="text" id="model">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="type" class="control-label">Type</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control api-fillable" name="type" type="text" id="type">
</div>
</div>
<hr/>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="manufacture_year" class="control-label">Bouwjaar en -maand</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control api-fillable" placeholder="jjjj" name="manufacture_year" type="text" id="manufacture_year">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="day_value" class="control-label">Dagwaarde</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control required" name="day_value" type="text" id="day_value">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="appraisal_value" class="control-label">Taxatiewaarde</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control required" name="appraisal_value" type="number" value="0" id="appraisal_value">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="member_fehac" class="control-label">Lid FEHAC</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon">€</div>
<select class="form-control" id="member_fehac" name="member_fehac"><option value="ja">Ja</option><option value="nee" selected="selected">Nee</option></select>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="col-lg-6 col-md-6 col-sm-12 col-xs-12">
<div class="panel panel-default">
<div class="panel-heading">Voertuig 1</div>
<div class="panel-body">
<div class="row">
<div class="col-xs-12">
<img class="full-size" src="https://app.example.net/img/car.jpg">
</div>
</div>
<div class="row">
<div class="col-xs-12">
<br/>
<span class="streetview-street"></span> <span class="streetview-housenumber"></span><br/>
<span class="streetview-postalcode"></span> <span class="streetview-city"></span><br/>
<span class="streetview-family-situation"></span>
<hr/>
</div>
</div>
<div class="row form-color-legend"></div> </div>
</div>
</div>
</div>
<div class="row">
<div class="col-lg-6 col-md-6 col-sm-12 col-xs-12">
<div class="panel panel-default">
<div class="panel-heading">Dekking</div>
<div class="panel-body">
<div class="row">
<div class="col-xs-12">
<hr/>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="mileage" class="control-label">Kilometrage</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon">km</div>
<input class="form-control" name="mileage" type="number" value="12000" id="mileage">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="coverage" class="control-label">Dekking</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7 inputinlabel">
<input id="coverage_wa" name="coverage" type="radio" value="wa">
<label for="coverage_wa" class="control-label">WA</label>
<input id="coverage_beperkt-casco" name="coverage" type="radio" value="beperkt-casco">
<label for="coverage_beperkt-casco" class="control-label">Beperkt casco</label>
<input id="coverage_volledig-casco" checked="checked" name="coverage" type="radio" value="volledig-casco">
<label for="coverage_volledig-casco" class="control-label">Volledig casco</label>
<input id="coverage_verschillend-per-maatschappij" name="coverage" type="radio" value="verschillend-per-maatschappij">
<label for="coverage_verschillend-per-maatschappij" class="control-label">Verschillend per maatschappij</label>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="own_risk_ahb" class="control-label">Eigen risico</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="own_risk_ahb" name="own_risk_ahb"><option value="geen-eigen-risico-of-zo-laag-mogelijk">Geen eigen risico of zo laag mogelijk</option><option value="met-eigen-risico-maar-zo-laag-mogelijk">Met eigen risico, maar zo laag mogelijk</option><option value="met-eigen-risico-maar-zo-hoog-mogelijk">Met eigen risico, maar zo hoog mogelijk</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-12 col-md-12 col-xs-12">
<div class="row">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="extended_coverages[]" class="control-label">Aanvullende dekkingen:</label>
</div>
</div>
<div class="row">
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_ovi-laag" name="extended_coverages[]" type="checkbox" value="ovi-laag">
<label for="extended_coverages_ovi-laag" class="control-label">OVI Laag</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_ovi-gem" name="extended_coverages[]" type="checkbox" value="ovi-gem">
<label for="extended_coverages_ovi-gem" class="control-label">OVI Gem.</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_ovi-hoog" name="extended_coverages[]" type="checkbox" value="ovi-hoog">
<label for="extended_coverages_ovi-hoog" class="control-label">OVI Hoog</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_svi-standaard" name="extended_coverages[]" type="checkbox" value="svi-standaard">
<label for="extended_coverages_svi-standaard" class="control-label">SVI (Standaard)</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_svi-uitgebreid" name="extended_coverages[]" type="checkbox" value="svi-uitgebreid">
<label for="extended_coverages_svi-uitgebreid" class="control-label">SVI (Uitgebreid)</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_verhaalshulp" name="extended_coverages[]" type="checkbox" value="verhaalshulp">
<label for="extended_coverages_verhaalshulp" class="control-label">Verhaalshulp</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_rechtsbijstand" name="extended_coverages[]" type="checkbox" value="rechtsbijstand">
<label for="extended_coverages_rechtsbijstand" class="control-label">Rechtsbijstand</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_rechtsbijstand-uitgebreid" name="extended_coverages[]" type="checkbox" value="rechtsbijstand-uitgebreid">
<label for="extended_coverages_rechtsbijstand-uitgebreid" class="control-label">Rechtsbijstand uitgebreid</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_pechhulp-nederland" name="extended_coverages[]" type="checkbox" value="pechhulp-nederland">
<label for="extended_coverages_pechhulp-nederland" class="control-label">Pechhulp Nederland</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_pechhulp-europa" name="extended_coverages[]" type="checkbox" value="pechhulp-europa">
<label for="extended_coverages_pechhulp-europa" class="control-label">Pechhulp Europa</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_max-aanschafwaarde" name="extended_coverages[]" type="checkbox" value="max-aanschafwaarde">
<label for="extended_coverages_max-aanschafwaarde" class="control-label">Max. aanschafwaarde</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_max-nieuwwaarde" name="extended_coverages[]" type="checkbox" value="max-nieuwwaarde">
<label for="extended_coverages_max-nieuwwaarde" class="control-label">Max. nieuwwaarde</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_no-claimbeschermer" name="extended_coverages[]" type="checkbox" value="no-claimbeschermer">
<label for="extended_coverages_no-claimbeschermer" class="control-label">No-claimbeschermer</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_winterstop" name="extended_coverages[]" type="checkbox" value="winterstop">
<label for="extended_coverages_winterstop" class="control-label">Winterstop</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_track-trace" name="extended_coverages[]" type="checkbox" value="track-trace">
<label for="extended_coverages_track-trace" class="control-label">Track Trace</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_vrije-keuze-herstel" name="extended_coverages[]" type="checkbox" value="vrije-keuze-herstel">
<label for="extended_coverages_vrije-keuze-herstel" class="control-label">Vrije keuze herstel</label>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row product-coverages" data-product="10">
<hr>
<div class="panel-group float full-width mb5" id="accordion" role="tablist" aria-multiselectable="true">
<div class="panel panel-default">
<div class="panel-heading" role="tab" id="headingOne">
<h4 class="panel-title">
<a class="collapsed" role="button" data-toggle="collapse" data-parent="#accordion"
href="#collapse_coverages_10"
aria-expanded="false" aria-controls="collapse_coverages_10">
Klik hier voor de dekkingen per maatschappij
</a>
</h4>
</div>
<div id="collapse_coverages_10" class="panel-collapse collapse" role="tabpanel"
aria-labelledby="headingOne">
<div class="panel-body">
<table class="table product-coverages-table">
<thead>
<tr>
<td>Maatschappij</td>
<td>Dekking</td>
</tr>
</thead>
<tbody>
<tr data-company="1">
<td>
<label class="control-label text-left">Unigarant</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="1" autocomplete="off">
<option value="54" data-selected-initially="1"
data-default-score="1"
data-realname="WA" selected>
WA
</option>
</select>
</td>
</tr>
<tr data-company="2">
<td>
<label class="control-label text-left">Nationale Nederlanden</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="2" autocomplete="off">
<option value="54" data-selected-initially="1"
data-default-score="1"
data-realname="WA" selected>
WA
</option>
</select>
</td>
</tr>
<tr data-company="3">
<td>
<label class="control-label text-left">a.s.r.</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="3" autocomplete="off">
<option value="54" data-selected-initially="1"
data-default-score="1"
data-realname="WA" selected>
WA
</option>
</select>
</td>
</tr>
<tr data-company="6">
<td>
<label class="control-label text-left">Reaal</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="6" autocomplete="off">
<option value="54" data-selected-initially="1"
data-default-score="1"
data-realname="WA" selected>
WA
</option>
</select>
</td>
</tr>
<tr data-company="7">
<td>
<label class="control-label text-left">Ansvar Idéa</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="7" autocomplete="off">
<option value="54" data-selected-initially="1"
data-default-score="1"
data-realname="WA" selected>
WA
</option>
</select>
</td>
</tr>
<tr data-company="8">
<td>
<label class="control-label text-left">Klaverblad</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="8" autocomplete="off">
<option value="54" data-selected-initially="1"
data-default-score="1"
data-realname="WA" selected>
WA
</option>
</select>
</td>
</tr>
<tr data-company="17">
<td>
<label class="control-label text-left">Turien en co.</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="17" autocomplete="off">
</select>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
</div>
</div> <div class="row product-risks-wrapper" data-product-id="10" data-product-name="Oldtimer auto"></div> </div>
</div>
</div>
<div class="col-lg-6 col-md-6 col-sm-12 col-xs-12">
<div class="panel panel-default">
<div class="panel-heading">Regelmatige bestuurder</div>
<div class="panel-body">
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_insurer_is_main_driver" class="control-label">Verzekeringnemer is regelmatige bestuurder</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input id="main_driver_insurer_is_main_driver_ja" name="main_driver_insurer_is_main_driver" type="radio" value="ja">
<label for="main_driver_insurer_is_main_driver_ja" class="control-label">ja</label>
<input id="main_driver_insurer_is_main_driver_nee" name="main_driver_insurer_is_main_driver" type="radio" value="nee">
<label for="main_driver_insurer_is_main_driver_nee" class="control-label">nee</label>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_person" class="control-label">Wie is regelmatige bestuurder</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input id="main_driver_person_partner" name="main_driver_person" type="radio" value="partner">
<label for="main_driver_person_partner" class="control-label">Partner</label>
<input id="main_driver_person_anders" name="main_driver_person" type="radio" value="anders">
<label for="main_driver_person_anders" class="control-label">Anders</label>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_birthdate" class="control-label">Geboortedatum</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon"><i class="fa fa-calendar"></i></div>
<input class="form-control" placeholder="dd-mm-jjjj" name="main_driver_birthdate" type="text" id="main_driver_birthdate">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_gender" class="control-label">Geslacht</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input id="main_driver_gender_man" name="main_driver_gender" type="radio" value="man">
<label for="main_driver_gender_man" class="control-label">Man</label>
<input id="main_driver_gender_vrouw" name="main_driver_gender" type="radio" value="vrouw">
<label for="main_driver_gender_vrouw" class="control-label">Vrouw</label>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_postcode" class="control-label">Postcode</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control required" name="main_driver_postcode" type="text" id="main_driver_postcode">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_housenumber" class="control-label">Huisnummer</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control" name="main_driver_housenumber" type="text" id="main_driver_housenumber">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_street" class="control-label">Straat</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control" name="main_driver_street" type="text" id="main_driver_street">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_city" class="control-label">Woonplaats</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control" name="main_driver_city" type="text" id="main_driver_city">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_claim_free_years" class="control-label">Schadevrije jaren</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="main_driver_claim_free_years" name="main_driver_claim_free_years"><option value="-6">-6</option><option value="-5">-5</option><option value="-4">-4</option><option value="-3">-3</option><option value="-2">-2</option><option value="-1">-1</option><option value="0" selected="selected">0</option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="8">8</option><option value="9">9</option><option value="10">10</option><option value="11">11</option><option value="12">12</option><option value="13">13</option><option value="14">14</option><option value="15">15</option><option value="16">16</option><option value="17">17</option><option value="18">18</option><option value="19">19</option><option value="20">20</option><option value="21">21</option><option value="22">22</option><option value="23">23</option><option value="24">24</option><option value="25">25</option><option value="26">26</option><option value="27">27</option><option value="28">28</option><option value="29">29</option><option value="30">30</option><option value="31">31</option><option value="32">32</option><option value="33">33</option><option value="34">34</option><option value="35">35</option><option value="36">36</option><option value="37">37</option><option value="38">38</option><option value="39">39</option><option value="40">40</option></select>
</div>
</div>
</div>
</div>
</div>
</div>
</form>
</div>
</div>
</div>
<div role="tabpanel" class="tab-pane" id="tab-van">
<div class="row tp-wrapper">
<div class="col-sm-12">
<form method="POST" action="https://app.example.net/app/van/store" accept-charset="UTF-8" class="form-horizontal"><input name="_token" type="hidden" value="LSJ7UMmOiFRd1ufN0UBhb4WuSKg907ZGCfXiwIym">
<div class="row">
<div class="col-lg-6 col-md-6 col-sm-12 col-xs-12">
<div class="panel panel-default">
<div class="panel-heading pull-left col-xs-12">
<div class="pull-left">Bestelautogegevens</div>
</div>
<div class="panel-body">
<p></p>
<br/>
<div class="row">
<div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
<input type="hidden" name="start_date" value="28-03-2018"/>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="license_plate" class="control-label">Kenteken</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control required" name="license_plate" type="text" id="license_plate">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="model_code" class="control-label">Meldcode</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control api-fillable" name="model_code" type="text" id="model_code">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="brand" class="control-label">Merk</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control api-fillable" name="brand" type="text" id="brand">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="model" class="control-label">Model</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control api-fillable" name="model" type="text" id="model">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="type" class="control-label">Type</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control api-fillable" name="type" type="text" id="type">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="weight" class="control-label">Gewicht</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon">KG</div>
<input class="form-control api-fillable" name="weight" type="text" value="0" id="weight">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="fuel_code" class="control-label">Brandstof</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control api-fillable" id="fuel_code" name="fuel_code"><option value="A">Alcohol</option><option value="B" selected="selected">Benzine</option><option value="C">Cryogeen</option><option value="D">Diesel</option><option value="E">Electrisch</option><option value="BE">Hybride benzine</option><option value="DE">Hybride diesel</option><option value="G">Gas (LPG / Propaan)</option><option value="H">Hogedruk gas</option><option value="W">Waterstof</option></select>
</div>
</div>
<hr/>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="imported" class="control-label">Voertuig geïmporteerd</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="imported" name="imported"><option value="nee">Nee</option><option value="ja">Ja</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="manufacture_year" class="control-label">Bouwjaar en -maand</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control api-fillable" placeholder="jjjj" name="manufacture_year" type="text" id="manufacture_year">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="new_value" class="control-label">Nieuwwaarde</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control api-fillable" name="new_value" type="text" id="new_value">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="day_value" class="control-label">Dagwaarde</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control" name="day_value" type="text" id="day_value">
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="col-lg-6 col-md-6 col-sm-12 col-xs-12">
<div class="panel panel-default">
<div class="panel-heading">Voertuig 1</div>
<div class="panel-body">
<div class="row">
<div class="col-xs-12">
<img class="full-size" src="https://app.example.net/img/car.jpg">
</div>
</div>
<div class="row">
<div class="col-xs-12">
<br/>
<span class="streetview-street"></span> <span class="streetview-housenumber"></span><br/>
<span class="streetview-postalcode"></span> <span class="streetview-city"></span><br/>
<span class="streetview-family-situation"></span>
<hr/>
</div>
</div>
<div class="row form-color-legend"></div> </div>
</div>
</div>
</div>
<div class="row">
<div class="col-lg-6 col-md-6 col-sm-12 col-xs-12">
<div class="panel panel-default">
<div class="panel-heading">Dekking</div>
<div class="panel-body">
<div class="row">
<div class="col-xs-12">
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="private_usage" class="control-label">Particulier gebruik</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="private_usage" name="private_usage"><option value="ja">Ja</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="incl_vat" class="control-label">Incl. BTW</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="incl_vat" name="incl_vat"><option value="ja">Ja</option><option value="nee">Nee</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="financed" class="control-label">Is het voertuig gefinancierd</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="financed" name="financed"><option value="nee">Nee</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="accessories_insured" class="control-label">Accessoires meeverzekeren?</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control" name="accessories_insured" type="number" value="0" id="accessories_insured">
</div>
</div>
</div>
<hr/>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="mileage" class="control-label">Kilometrage</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon">km</div>
<input class="form-control" name="mileage" type="number" value="12000" id="mileage">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="coverage" class="control-label">Dekking</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7 inputinlabel">
<input id="coverage_wa" name="coverage" type="radio" value="wa">
<label for="coverage_wa" class="control-label">WA</label>
<input id="coverage_beperkt-casco" name="coverage" type="radio" value="beperkt-casco">
<label for="coverage_beperkt-casco" class="control-label">Beperkt casco</label>
<input id="coverage_volledig-casco" checked="checked" name="coverage" type="radio" value="volledig-casco">
<label for="coverage_volledig-casco" class="control-label">Volledig casco</label>
<input id="coverage_verschillend-per-maatschappij" name="coverage" type="radio" value="verschillend-per-maatschappij">
<label for="coverage_verschillend-per-maatschappij" class="control-label">Verschillend per maatschappij</label>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="own_risk_ahb" class="control-label">Eigen risico</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="own_risk_ahb" name="own_risk_ahb"><option value="geen-eigen-risico-of-zo-laag-mogelijk">Geen eigen risico of zo laag mogelijk</option><option value="met-eigen-risico-maar-zo-laag-mogelijk">Met eigen risico, maar zo laag mogelijk</option><option value="met-eigen-risico-maar-zo-hoog-mogelijk">Met eigen risico, maar zo hoog mogelijk</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="own_risk_non_ahb" class="control-label">Vrijwillig eigen risico</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="own_risk_non_ahb" name="own_risk_non_ahb"><option value="geen-eigen-risico-of-zo-laag-mogelijk">Geen eigen risico of zo laag mogelijk</option><option value="met-eigen-risico-maar-zo-laag-mogelijk">Met eigen risico, maar zo laag mogelijk</option><option value="met-eigen-risico-maar-zo-hoog-mogelijk">Met eigen risico, maar zo hoog mogelijk</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-12 col-md-12 col-xs-12">
<div class="row">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="extended_coverages[]" class="control-label">Aanvullende dekkingen:</label>
</div>
</div>
<div class="row">
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_ovi-laag" name="extended_coverages[]" type="checkbox" value="ovi-laag">
<label for="extended_coverages_ovi-laag" class="control-label">OVI Laag</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_ovi-gem" name="extended_coverages[]" type="checkbox" value="ovi-gem">
<label for="extended_coverages_ovi-gem" class="control-label">OVI Gem.</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_ovi-hoog" name="extended_coverages[]" type="checkbox" value="ovi-hoog">
<label for="extended_coverages_ovi-hoog" class="control-label">OVI Hoog</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_svi-standaard" name="extended_coverages[]" type="checkbox" value="svi-standaard">
<label for="extended_coverages_svi-standaard" class="control-label">SVI (Standaard)</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_svi-uitgebreid" name="extended_coverages[]" type="checkbox" value="svi-uitgebreid">
<label for="extended_coverages_svi-uitgebreid" class="control-label">SVI (Uitgebreid)</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_verhaalshulp" name="extended_coverages[]" type="checkbox" value="verhaalshulp">
<label for="extended_coverages_verhaalshulp" class="control-label">Verhaalshulp</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_rechtsbijstand" name="extended_coverages[]" type="checkbox" value="rechtsbijstand">
<label for="extended_coverages_rechtsbijstand" class="control-label">Rechtsbijstand</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_rechtsbijstand-uitgebreid" name="extended_coverages[]" type="checkbox" value="rechtsbijstand-uitgebreid">
<label for="extended_coverages_rechtsbijstand-uitgebreid" class="control-label">Rechtsbijstand uitgebreid</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_pechhulp-nederland" name="extended_coverages[]" type="checkbox" value="pechhulp-nederland">
<label for="extended_coverages_pechhulp-nederland" class="control-label">Pechhulp Nederland</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_pechhulp-europa" name="extended_coverages[]" type="checkbox" value="pechhulp-europa">
<label for="extended_coverages_pechhulp-europa" class="control-label">Pechhulp Europa</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_max-aanschafwaarde" name="extended_coverages[]" type="checkbox" value="max-aanschafwaarde">
<label for="extended_coverages_max-aanschafwaarde" class="control-label">Max. aanschafwaarde</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_max-nieuwwaarde" name="extended_coverages[]" type="checkbox" value="max-nieuwwaarde">
<label for="extended_coverages_max-nieuwwaarde" class="control-label">Max. nieuwwaarde</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_no-claimbeschermer" name="extended_coverages[]" type="checkbox" value="no-claimbeschermer">
<label for="extended_coverages_no-claimbeschermer" class="control-label">No-claimbeschermer</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_winterstop" name="extended_coverages[]" type="checkbox" value="winterstop">
<label for="extended_coverages_winterstop" class="control-label">Winterstop</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_track-trace" name="extended_coverages[]" type="checkbox" value="track-trace">
<label for="extended_coverages_track-trace" class="control-label">Track Trace</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_vrije-keuze-herstel" name="extended_coverages[]" type="checkbox" value="vrije-keuze-herstel">
<label for="extended_coverages_vrije-keuze-herstel" class="control-label">Vrije keuze herstel</label>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row product-coverages" data-product="13">
<hr>
<div class="panel-group float full-width mb5" id="accordion" role="tablist" aria-multiselectable="true">
<div class="panel panel-default">
<div class="panel-heading" role="tab" id="headingOne">
<h4 class="panel-title">
<a class="collapsed" role="button" data-toggle="collapse" data-parent="#accordion"
href="#collapse_coverages_13"
aria-expanded="false" aria-controls="collapse_coverages_13">
Klik hier voor de dekkingen per maatschappij
</a>
</h4>
</div>
<div id="collapse_coverages_13" class="panel-collapse collapse" role="tabpanel"
aria-labelledby="headingOne">
<div class="panel-body">
<table class="table product-coverages-table">
<thead>
<tr>
<td>Maatschappij</td>
<td>Dekking</td>
</tr>
</thead>
<tbody>
<tr data-company="1">
<td>
<label class="control-label text-left">Unigarant</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="1" autocomplete="off">
</select>
</td>
</tr>
<tr data-company="2">
<td>
<label class="control-label text-left">Nationale Nederlanden</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="2" autocomplete="off">
</select>
</td>
</tr>
<tr data-company="3">
<td>
<label class="control-label text-left">a.s.r.</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="3" autocomplete="off">
</select>
</td>
</tr>
<tr data-company="6">
<td>
<label class="control-label text-left">Reaal</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="6" autocomplete="off">
</select>
</td>
</tr>
<tr data-company="7">
<td>
<label class="control-label text-left">Ansvar Idéa</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="7" autocomplete="off">
</select>
</td>
</tr>
<tr data-company="8">
<td>
<label class="control-label text-left">Klaverblad</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="8" autocomplete="off">
</select>
</td>
</tr>
<tr data-company="17">
<td>
<label class="control-label text-left">Turien en co.</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="17" autocomplete="off">
</select>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
</div>
</div> <div class="row product-risks-wrapper" data-product-id="13" data-product-name="Bestelauto"></div> </div>
</div>
</div>
<div class="col-lg-6 col-md-6 col-sm-12 col-xs-12">
<div class="panel panel-default">
<div class="panel-heading">Regelmatige bestuurder</div>
<div class="panel-body">
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_insurer_is_main_driver" class="control-label">Verzekeringnemer is regelmatige bestuurder</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input id="main_driver_insurer_is_main_driver_ja" name="main_driver_insurer_is_main_driver" type="radio" value="ja">
<label for="main_driver_insurer_is_main_driver_ja" class="control-label">ja</label>
<input id="main_driver_insurer_is_main_driver_nee" name="main_driver_insurer_is_main_driver" type="radio" value="nee">
<label for="main_driver_insurer_is_main_driver_nee" class="control-label">nee</label>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_person" class="control-label">Wie is regelmatige bestuurder</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input id="main_driver_person_partner" name="main_driver_person" type="radio" value="partner">
<label for="main_driver_person_partner" class="control-label">Partner</label>
<input id="main_driver_person_anders" name="main_driver_person" type="radio" value="anders">
<label for="main_driver_person_anders" class="control-label">Anders</label>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_birthdate" class="control-label">Geboortedatum</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon"><i class="fa fa-calendar"></i></div>
<input class="form-control" placeholder="dd-mm-jjjj" name="main_driver_birthdate" type="text" id="main_driver_birthdate">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_gender" class="control-label">Geslacht</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input id="main_driver_gender_man" name="main_driver_gender" type="radio" value="man">
<label for="main_driver_gender_man" class="control-label">Man</label>
<input id="main_driver_gender_vrouw" name="main_driver_gender" type="radio" value="vrouw">
<label for="main_driver_gender_vrouw" class="control-label">Vrouw</label>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_postcode" class="control-label">Postcode</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control required" name="main_driver_postcode" type="text" id="main_driver_postcode">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_housenumber" class="control-label">Huisnummer</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control" name="main_driver_housenumber" type="text" id="main_driver_housenumber">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_street" class="control-label">Straat</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control" name="main_driver_street" type="text" id="main_driver_street">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_city" class="control-label">Woonplaats</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control" name="main_driver_city" type="text" id="main_driver_city">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_claim_free_years" class="control-label">Schadevrije jaren</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="main_driver_claim_free_years" name="main_driver_claim_free_years"><option value="-6">-6</option><option value="-5">-5</option><option value="-4">-4</option><option value="-3">-3</option><option value="-2">-2</option><option value="-1">-1</option><option value="0" selected="selected">0</option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="8">8</option><option value="9">9</option><option value="10">10</option><option value="11">11</option><option value="12">12</option><option value="13">13</option><option value="14">14</option><option value="15">15</option><option value="16">16</option><option value="17">17</option><option value="18">18</option><option value="19">19</option><option value="20">20</option><option value="21">21</option><option value="22">22</option><option value="23">23</option><option value="24">24</option><option value="25">25</option><option value="26">26</option><option value="27">27</option><option value="28">28</option><option value="29">29</option><option value="30">30</option><option value="31">31</option><option value="32">32</option><option value="33">33</option><option value="34">34</option><option value="35">35</option><option value="36">36</option><option value="37">37</option><option value="38">38</option><option value="39">39</option><option value="40">40</option></select>
</div>
</div>
</div>
</div>
</div>
</div>
</form>
</div>
</div>
</div>
<div role="tabpanel" class="tab-pane" id="tab-caravan">
<div class="row tp-wrapper">
<div class="col-sm-12">
<form method="POST" action="https://app.example.net/app/caravan/store" accept-charset="UTF-8" class="form-horizontal"><input name="_token" type="hidden" value="LSJ7UMmOiFRd1ufN0UBhb4WuSKg907ZGCfXiwIym">
<div class="row">
<div class="col-lg-6 col-md-6 col-sm-12 col-xs-12">
<div class="panel panel-default">
<div class="panel-heading pull-left col-xs-12">
<div class="pull-left">Caravangegevens</div>
</div>
<div class="panel-body">
<p></p>
<br/>
<div class="row">
<div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
<input type="hidden" name="start_date" value="28-03-2018"/>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="new_or_occasion" class="control-label">Nieuw of occasion</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="new_or_occasion" name="new_or_occasion"><option value="nieuw">Nieuw</option><option value="occasion">Occasion</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="license_plate" class="control-label">Kenteken</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control" name="license_plate" type="text" id="license_plate">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="model_code" class="control-label">Meldcode</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control api-fillable" name="model_code" type="text" id="model_code">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="brand" class="control-label">Merk</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control" name="brand" type="text" id="brand">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="model" class="control-label">Model</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control" name="model" type="text" id="model">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="type" class="control-label">Type</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="type" name="type"><option value="toercaravan">Toercaravan</option><option value="stacaravan">Stacaravan</option><option value="vouw-en-bagage">Vouw- en bagage</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="overall_length" class="control-label">Totale opbouwlengte</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="overall_length" name="overall_length"><option value="tot-5-meter">Tot 5 meter</option><option value="meer-dan-5-meter">Meer dan 5 meter</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="manufacture_year" class="control-label">Bouwjaar en -maand</label>
<label for="manufacture_month" class="control-label">Bouwmaand</label>
</div>
<div class="col-lg-4 col-md-4 col-xs-4">
<input class="form-control" placeholder="jjjj" name="manufacture_year" type="text" id="manufacture_year">
</div>
<div class="col-lg-4 col-md-4 col-xs-4">
<input class="form-control" placeholder="mm" name="manufacture_month" type="text" id="manufacture_month">
</div>
</div>
<hr/>
<h3>Verzekerde bedragen</h3>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="new_value" class="control-label">Nieuwwaarde</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control api-fillable" name="new_value" type="text" id="new_value">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="inventory_value" class="control-label">Inventaris waarde</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control" name="inventory_value" type="text" id="inventory_value">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="accessories_insured" class="control-label">Accessoires</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control" name="accessories_insured" type="number" value="0" id="accessories_insured">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="awning_or_canopy_value" class="control-label">Voortent/luifel</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control" name="awning_or_canopy_value" type="text" id="awning_or_canopy_value">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="mover_value" class="control-label">Mover</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control" name="mover_value" type="text" id="mover_value">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="extension_value" class="control-label">Aanbouw</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control" name="extension_value" type="text" id="extension_value">
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="col-lg-6 col-md-6 col-sm-12 col-xs-12">
<div class="panel panel-default">
<div class="panel-heading">Voertuig 1</div>
<div class="panel-body">
<div class="row">
<div class="col-xs-12">
<img class="full-size" src="https://app.example.net/img/car.jpg">
</div>
</div>
<div class="row">
<div class="col-xs-12">
<br/>
<span class="streetview-street"></span> <span class="streetview-housenumber"></span><br/>
<span class="streetview-postalcode"></span> <span class="streetview-city"></span><br/>
<span class="streetview-family-situation"></span>
<hr/>
</div>
</div>
<div class="row form-color-legend"></div> </div>
</div>
</div>
</div>
<div class="row">
<div class="col-lg-6 col-md-6 col-sm-12 col-xs-12">
<div class="panel panel-default">
<div class="panel-heading">Dekking</div>
<div class="panel-body">
<div class="row">
<div class="col-xs-12">
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="coverage" class="control-label">Dekking</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7 inputinlabel">
<input id="coverage_wa" name="coverage" type="radio" value="wa">
<label for="coverage_wa" class="control-label">WA</label>
<input id="coverage_beperkt-casco" name="coverage" type="radio" value="beperkt-casco">
<label for="coverage_beperkt-casco" class="control-label">Beperkt casco</label>
<input id="coverage_casco" name="coverage" type="radio" value="casco">
<label for="coverage_casco" class="control-label">Casco</label>
<input id="coverage_standaard-wa" name="coverage" type="radio" value="standaard-wa">
<label for="coverage_standaard-wa" class="control-label">Standaard WA</label>
<input id="coverage_verschillend-per-maatschappij" name="coverage" type="radio" value="verschillend-per-maatschappij">
<label for="coverage_verschillend-per-maatschappij" class="control-label">Verschillend per maatschappij</label>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="own_risk_ahb" class="control-label">Eigen risico</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="own_risk_ahb" name="own_risk_ahb"><option value="geen-eigen-risico-of-zo-laag-mogelijk">Geen eigen risico of zo laag mogelijk</option><option value="met-eigen-risico-maar-zo-laag-mogelijk">Met eigen risico, maar zo laag mogelijk</option><option value="met-eigen-risico-maar-zo-hoog-mogelijk">Met eigen risico, maar zo hoog mogelijk</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="value_coverage_type" class="control-label">Dekkingswaarde</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="value_coverage_type" name="value_coverage_type"><option value="dagwaarde">Dagwaarde</option><option value="nieuwwaarde">Nieuwwaarde</option><option value="5-jaar-nieuwwaarde">5 jaar nieuwwaarde</option><option value="10-jaar-nieuwwaarde">10 jaar nieuwwaarde</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-12 col-md-12 col-xs-12">
<div class="row">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="extended_coverages[]" class="control-label">Aanvullende dekkingen:</label>
</div>
</div>
<div class="row">
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_nieuwwaarde-garantie" name="extended_coverages[]" type="checkbox" value="nieuwwaarde-garantie">
<label for="extended_coverages_nieuwwaarde-garantie" class="control-label">Nieuwwaarde garantie</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_hagel-en-stormschade" name="extended_coverages[]" type="checkbox" value="hagel-en-stormschade">
<label for="extended_coverages_hagel-en-stormschade" class="control-label">Hagel- en stormschade</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_rechtsbijstand" name="extended_coverages[]" type="checkbox" value="rechtsbijstand">
<label for="extended_coverages_rechtsbijstand" class="control-label">Rechtsbijstand</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_hagelbestendig-dak" name="extended_coverages[]" type="checkbox" value="hagelbestendig-dak">
<label for="extended_coverages_hagelbestendig-dak" class="control-label">Hagelbestendig dak</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_verhuur" name="extended_coverages[]" type="checkbox" value="verhuur">
<label for="extended_coverages_verhuur" class="control-label">Verhuur</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_anwb-lid" name="extended_coverages[]" type="checkbox" value="anwb-lid">
<label for="extended_coverages_anwb-lid" class="control-label">ANWB-lid</label>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row product-coverages" data-product="14">
<hr>
<div class="panel-group float full-width mb5" id="accordion" role="tablist" aria-multiselectable="true">
<div class="panel panel-default">
<div class="panel-heading" role="tab" id="headingOne">
<h4 class="panel-title">
<a class="collapsed" role="button" data-toggle="collapse" data-parent="#accordion"
href="#collapse_coverages_14"
aria-expanded="false" aria-controls="collapse_coverages_14">
Klik hier voor de dekkingen per maatschappij
</a>
</h4>
</div>
<div id="collapse_coverages_14" class="panel-collapse collapse" role="tabpanel"
aria-labelledby="headingOne">
<div class="panel-body">
<table class="table product-coverages-table">
<thead>
<tr>
<td>Maatschappij</td>
<td>Dekking</td>
</tr>
</thead>
<tbody>
<tr data-company="1">
<td>
<label class="control-label text-left">Unigarant</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="1" autocomplete="off">
</select>
</td>
</tr>
<tr data-company="2">
<td>
<label class="control-label text-left">Nationale Nederlanden</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="2" autocomplete="off">
</select>
</td>
</tr>
<tr data-company="3">
<td>
<label class="control-label text-left">a.s.r.</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="3" autocomplete="off">
</select>
</td>
</tr>
<tr data-company="6">
<td>
<label class="control-label text-left">Reaal</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="6" autocomplete="off">
</select>
</td>
</tr>
<tr data-company="7">
<td>
<label class="control-label text-left">Ansvar Idéa</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="7" autocomplete="off">
</select>
</td>
</tr>
<tr data-company="8">
<td>
<label class="control-label text-left">Klaverblad</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="8" autocomplete="off">
</select>
</td>
</tr>
<tr data-company="17">
<td>
<label class="control-label text-left">Turien en co.</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="17" autocomplete="off">
</select>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
</div>
</div> <div class="row product-risks-wrapper" data-product-id="14" data-product-name="Caravan"></div> </div>
</div>
</div>
</div>
</form>
</div>
</div>
</div>
<div role="tabpanel" class="tab-pane" id="tab-camper">
<div class="row tp-wrapper">
<div class="col-sm-12">
<form method="POST" action="https://app.example.net/app/camper/store" accept-charset="UTF-8" class="form-horizontal"><input name="_token" type="hidden" value="LSJ7UMmOiFRd1ufN0UBhb4WuSKg907ZGCfXiwIym">
<div class="row">
<div class="col-lg-6 col-md-6 col-sm-12 col-xs-12">
<div class="panel panel-default">
<div class="panel-heading pull-left col-xs-12">
<div class="pull-left">Kampeerautogegevens</div>
</div>
<div class="panel-body">
<p></p>
<br/>
<div class="row">
<div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
<input type="hidden" name="start_date" value="28-03-2018"/>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="new_or_occasion" class="control-label">Nieuw of occasion</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="new_or_occasion" name="new_or_occasion"><option value="nieuw">Nieuw</option><option value="occasion">Occasion</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="license_plate" class="control-label">Kenteken</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control" name="license_plate" type="text" id="license_plate">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="model_code" class="control-label">Meldcode</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control api-fillable" name="model_code" type="text" id="model_code">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="brand" class="control-label">Merk</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control" name="brand" type="text" id="brand">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="model" class="control-label">Model</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control" name="model" type="text" id="model">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="type" class="control-label">Type</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control" name="type" type="text" id="type">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="overall_length" class="control-label">Totale opbouwlengte</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="overall_length" name="overall_length"><option value="tot-5-meter">Tot 5 meter</option><option value="meer-dan-5-meter">Meer dan 5 meter</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="weight" class="control-label">Gewicht</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon">KG</div>
<input class="form-control" name="weight" type="text" value="0" id="weight">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="manufacture_year" class="control-label">Bouwjaar en -maand</label>
<label for="manufacture_month" class="control-label">Bouwmaand</label>
</div>
<div class="col-lg-4 col-md-4 col-xs-4">
<input class="form-control" placeholder="jjjj" name="manufacture_year" type="text" id="manufacture_year">
</div>
<div class="col-lg-4 col-md-4 col-xs-4">
<input class="form-control" placeholder="mm" name="manufacture_month" type="text" id="manufacture_month">
</div>
</div>
<hr/>
<h3>Verzekerde bedragen</h3>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="new_value" class="control-label">Nieuwwaarde</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control api-fillable" name="new_value" type="text" id="new_value">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="inventory_value" class="control-label">Inventaris waarde</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control" name="inventory_value" type="text" id="inventory_value">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="accessories_insured" class="control-label">Accessoires meeverzekeren?</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control" name="accessories_insured" type="number" value="0" id="accessories_insured">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="awning_or_canopy_value" class="control-label">Voortent/luifel</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control" name="awning_or_canopy_value" type="text" id="awning_or_canopy_value">
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="col-lg-6 col-md-6 col-sm-12 col-xs-12">
<div class="panel panel-default">
<div class="panel-heading">Voertuig 1</div>
<div class="panel-body">
<div class="row">
<div class="col-xs-12">
<img class="full-size" src="https://app.example.net/img/car.jpg">
</div>
</div>
<div class="row">
<div class="col-xs-12">
<br/>
<span class="streetview-street"></span> <span class="streetview-housenumber"></span><br/>
<span class="streetview-postalcode"></span> <span class="streetview-city"></span><br/>
<span class="streetview-family-situation"></span>
<hr/>
</div>
</div>
<div class="row form-color-legend"></div> </div>
</div>
</div>
</div>
<div class="row">
<div class="col-lg-6 col-md-6 col-sm-12 col-xs-12">
<div class="panel panel-default">
<div class="panel-heading">Dekking</div>
<div class="panel-body">
<div class="row">
<div class="col-xs-12">
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="coverage" class="control-label">Dekking</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7 inputinlabel">
<input id="coverage_wa" name="coverage" type="radio" value="wa">
<label for="coverage_wa" class="control-label">WA</label>
<input id="coverage_beperkt-casco" name="coverage" type="radio" value="beperkt-casco">
<label for="coverage_beperkt-casco" class="control-label">Beperkt casco</label>
<input id="coverage_casco" name="coverage" type="radio" value="casco">
<label for="coverage_casco" class="control-label">Casco</label>
<input id="coverage_standaard-wa" name="coverage" type="radio" value="standaard-wa">
<label for="coverage_standaard-wa" class="control-label">Standaard WA</label>
<input id="coverage_verschillend-per-maatschappij" name="coverage" type="radio" value="verschillend-per-maatschappij">
<label for="coverage_verschillend-per-maatschappij" class="control-label">Verschillend per maatschappij</label>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="own_risk_ahb" class="control-label">Eigen risico</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="own_risk_ahb" name="own_risk_ahb"><option value="geen-eigen-risico-of-zo-laag-mogelijk">Geen eigen risico of zo laag mogelijk</option><option value="met-eigen-risico-maar-zo-laag-mogelijk">Met eigen risico, maar zo laag mogelijk</option><option value="met-eigen-risico-maar-zo-hoog-mogelijk">Met eigen risico, maar zo hoog mogelijk</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="value_coverage_type" class="control-label">Dekkingswaarde</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="value_coverage_type" name="value_coverage_type"><option value="dagwaarde">Dagwaarde</option><option value="nieuwwaarde">Nieuwwaarde</option><option value="5-jaar-nieuwwaarde">5 jaar nieuwwaarde</option><option value="10-jaar-nieuwwaarde">10 jaar nieuwwaarde</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-12 col-md-12 col-xs-12">
<div class="row">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="extended_coverages[]" class="control-label">Aanvullende dekkingen:</label>
</div>
</div>
<div class="row">
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_ovi-laag" name="extended_coverages[]" type="checkbox" value="ovi-laag">
<label for="extended_coverages_ovi-laag" class="control-label">OVI Laag</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_ovi-gem" name="extended_coverages[]" type="checkbox" value="ovi-gem">
<label for="extended_coverages_ovi-gem" class="control-label">OVI Gem.</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_ovi-hoog" name="extended_coverages[]" type="checkbox" value="ovi-hoog">
<label for="extended_coverages_ovi-hoog" class="control-label">OVI Hoog</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_svi-standaard" name="extended_coverages[]" type="checkbox" value="svi-standaard">
<label for="extended_coverages_svi-standaard" class="control-label">SVI (Standaard)</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_svi-uitgebreid" name="extended_coverages[]" type="checkbox" value="svi-uitgebreid">
<label for="extended_coverages_svi-uitgebreid" class="control-label">SVI (Uitgebreid)</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_verhaalshulp" name="extended_coverages[]" type="checkbox" value="verhaalshulp">
<label for="extended_coverages_verhaalshulp" class="control-label">Verhaalshulp</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_rechtsbijstand" name="extended_coverages[]" type="checkbox" value="rechtsbijstand">
<label for="extended_coverages_rechtsbijstand" class="control-label">Rechtsbijstand</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_verhuur" name="extended_coverages[]" type="checkbox" value="verhuur">
<label for="extended_coverages_verhuur" class="control-label">Verhuur</label>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row product-coverages" data-product="18">
<hr>
<div class="panel-group float full-width mb5" id="accordion" role="tablist" aria-multiselectable="true">
<div class="panel panel-default">
<div class="panel-heading" role="tab" id="headingOne">
<h4 class="panel-title">
<a class="collapsed" role="button" data-toggle="collapse" data-parent="#accordion"
href="#collapse_coverages_18"
aria-expanded="false" aria-controls="collapse_coverages_18">
Klik hier voor de dekkingen per maatschappij
</a>
</h4>
</div>
<div id="collapse_coverages_18" class="panel-collapse collapse" role="tabpanel"
aria-labelledby="headingOne">
<div class="panel-body">
<table class="table product-coverages-table">
<thead>
<tr>
<td>Maatschappij</td>
<td>Dekking</td>
</tr>
</thead>
<tbody>
<tr data-company="1">
<td>
<label class="control-label text-left">Unigarant</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="1" autocomplete="off">
<option value="63" data-selected-initially="1"
data-default-score="1"
data-realname="WA" selected>
WA
</option>
</select>
</td>
</tr>
<tr data-company="2">
<td>
<label class="control-label text-left">Nationale Nederlanden</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="2" autocomplete="off">
<option value="63" data-selected-initially="1"
data-default-score="1"
data-realname="WA" selected>
WA
</option>
</select>
</td>
</tr>
<tr data-company="3">
<td>
<label class="control-label text-left">a.s.r.</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="3" autocomplete="off">
<option value="63" data-selected-initially="1"
data-default-score="1"
data-realname="WA" selected>
WA
</option>
</select>
</td>
</tr>
<tr data-company="6">
<td>
<label class="control-label text-left">Reaal</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="6" autocomplete="off">
<option value="63" data-selected-initially="1"
data-default-score="1"
data-realname="WA" selected>
WA
</option>
</select>
</td>
</tr>
<tr data-company="7">
<td>
<label class="control-label text-left">Ansvar Idéa</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="7" autocomplete="off">
<option value="63" data-selected-initially="1"
data-default-score="1"
data-realname="WA" selected>
WA
</option>
</select>
</td>
</tr>
<tr data-company="8">
<td>
<label class="control-label text-left">Klaverblad</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="8" autocomplete="off">
<option value="63" data-selected-initially="1"
data-default-score="1"
data-realname="WA" selected>
WA
</option>
</select>
</td>
</tr>
<tr data-company="17">
<td>
<label class="control-label text-left">Turien en co.</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="17" autocomplete="off">
</select>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
</div>
</div> <div class="row product-risks-wrapper" data-product-id="18" data-product-name="Kampeerauto"></div> </div>
</div>
</div>
<div class="col-lg-6 col-md-6 col-sm-12 col-xs-12">
<div class="panel panel-default">
<div class="panel-heading">Regelmatige bestuurder</div>
<div class="panel-body">
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_birthdate" class="control-label">Geboortedatum</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon"><i class="fa fa-calendar"></i></div>
<input class="form-control" placeholder="dd-mm-jjjj" name="main_driver_birthdate" type="text" id="main_driver_birthdate">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_claim_free_years" class="control-label">Schadevrije jaren</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="main_driver_claim_free_years" name="main_driver_claim_free_years"><option value="-6">-6</option><option value="-5">-5</option><option value="-4">-4</option><option value="-3">-3</option><option value="-2">-2</option><option value="-1">-1</option><option value="0" selected="selected">0</option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="8">8</option><option value="9">9</option><option value="10">10</option><option value="11">11</option><option value="12">12</option><option value="13">13</option><option value="14">14</option><option value="15">15</option><option value="16">16</option><option value="17">17</option><option value="18">18</option><option value="19">19</option><option value="20">20</option><option value="21">21</option><option value="22">22</option><option value="23">23</option><option value="24">24</option><option value="25">25</option><option value="26">26</option><option value="27">27</option><option value="28">28</option><option value="29">29</option><option value="30">30</option><option value="31">31</option><option value="32">32</option><option value="33">33</option><option value="34">34</option><option value="35">35</option><option value="36">36</option><option value="37">37</option><option value="38">38</option><option value="39">39</option><option value="40">40</option></select>
</div>
</div>
</div>
</div>
</div>
</div>
</form>
</div>
</div>
</div>
<div role="tabpanel" class="tab-pane" id="tab-motorcycle">
<div class="row tp-wrapper">
<div class="col-sm-12">
<form method="POST" action="https://app.example.net/app/motorcycle/store" accept-charset="UTF-8" class="form-horizontal"><input name="_token" type="hidden" value="LSJ7UMmOiFRd1ufN0UBhb4WuSKg907ZGCfXiwIym">
<div class="row">
<div class="col-lg-6 col-md-6 col-sm-12 col-xs-12">
<div class="panel panel-default">
<div class="panel-heading pull-left col-xs-12">
<div class="pull-left">Motorgegevens</div>
</div>
<div class="panel-body">
<p></p>
<br/>
<div class="row">
<div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
<input type="hidden" name="start_date" value="28-03-2018"/>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="license_plate" class="control-label">Kenteken</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control required" name="license_plate" type="text" id="license_plate">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="model_code" class="control-label">Meldcode</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control api-fillable" name="model_code" type="text" id="model_code">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="brand" class="control-label">Merk</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control api-fillable" name="brand" type="text" id="brand">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="model" class="control-label">Model</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control api-fillable" name="model" type="text" id="model">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="type" class="control-label">Type</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control api-fillable" name="type" type="text" id="type">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="vehicle_type" class="control-label">Motor / Quad / Trike</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="vehicle_type" name="vehicle_type"><option value="motor" selected="selected">Motor</option><option value="quad">Quad</option><option value="trike">Trike</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="weight" class="control-label">Gewicht</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon">KG</div>
<input class="form-control api-fillable" name="weight" type="text" value="0" id="weight">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="kw" class="control-label">KW</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control api-fillable" name="kw" type="text" value="0" id="kw">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="motor_contents" class="control-label">Motorinhoud in CC</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control api-fillable" name="motor_contents" type="text" value="0" id="motor_contents">
</div>
</div>
<hr/>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="imported" class="control-label">Voertuig geïmporteerd</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="imported" name="imported"><option value="nee">Nee</option><option value="ja">Ja</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="manufacture_year" class="control-label">Bouwjaar en -maand</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control api-fillable" placeholder="jjjj" name="manufacture_year" type="text" id="manufacture_year">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="new_value" class="control-label">Nieuwwaarde</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control api-fillable" name="new_value" type="text" id="new_value">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="day_value" class="control-label">Dagwaarde</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control" name="day_value" type="text" id="day_value">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="appraisal_value" class="control-label">Taxatiewaarde</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control required" name="appraisal_value" type="number" value="0" id="appraisal_value">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="appraisal_date" class="control-label">Taxatiedatum</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon"><i class="fa fa-calendar"></i></div>
<input class="form-control" placeholder="dd-mm-jjjj" name="appraisal_date" type="text" id="appraisal_date">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="self_build" class="control-label">Eigenbouw</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="self_build" name="self_build"><option value="ja">Ja</option><option value="nee" selected="selected">Nee</option></select>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="col-lg-6 col-md-6 col-sm-12 col-xs-12">
<div class="panel panel-default">
<div class="panel-heading">Voertuig 1</div>
<div class="panel-body">
<div class="row">
<div class="col-xs-12">
<img class="full-size" src="https://app.example.net/img/car.jpg">
</div>
</div>
<div class="row">
<div class="col-xs-12">
<br/>
<span class="streetview-street"></span> <span class="streetview-housenumber"></span><br/>
<span class="streetview-postalcode"></span> <span class="streetview-city"></span><br/>
<span class="streetview-family-situation"></span>
<hr/>
</div>
</div>
<div class="row form-color-legend"></div> </div>
</div>
</div>
</div>
<div class="row">
<div class="col-lg-6 col-md-6 col-sm-12 col-xs-12">
<div class="panel panel-default">
<div class="panel-heading">Dekking</div>
<div class="panel-body">
<div class="row">
<div class="col-xs-12">
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="private_usage" class="control-label">Particulier gebruik</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="private_usage" name="private_usage"><option value="ja">Ja</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="incl_vat" class="control-label">Incl. BTW</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="incl_vat" name="incl_vat"><option value="ja">Ja</option><option value="nee">Nee</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="financed" class="control-label">Is het voertuig gefinancierd</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="financed" name="financed"><option value="nee">Nee</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="accessories_insured" class="control-label">Accessoires meeverzekeren?</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control" name="accessories_insured" type="number" value="0" id="accessories_insured">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="bagage_insured" class="control-label">Helm, kleding en bagage</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control" name="bagage_insured" type="number" value="0" id="bagage_insured">
</div>
</div>
</div>
<hr/>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="mileage" class="control-label">Kilometrage</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon">km</div>
<input class="form-control" name="mileage" type="number" value="12000" id="mileage">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="coverage" class="control-label">Dekking</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7 inputinlabel">
<input id="coverage_wa" name="coverage" type="radio" value="wa">
<label for="coverage_wa" class="control-label">WA</label>
<input id="coverage_beperkt-casco" name="coverage" type="radio" value="beperkt-casco">
<label for="coverage_beperkt-casco" class="control-label">Beperkt casco</label>
<input id="coverage_volledig-casco" checked="checked" name="coverage" type="radio" value="volledig-casco">
<label for="coverage_volledig-casco" class="control-label">Volledig casco</label>
<input id="coverage_verschillend-per-maatschappij" name="coverage" type="radio" value="verschillend-per-maatschappij">
<label for="coverage_verschillend-per-maatschappij" class="control-label">Verschillend per maatschappij</label>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="own_risk_ahb" class="control-label">Eigen risico</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="own_risk_ahb" name="own_risk_ahb"><option value="geen-eigen-risico-of-zo-laag-mogelijk">Geen eigen risico of zo laag mogelijk</option><option value="met-eigen-risico-maar-zo-laag-mogelijk">Met eigen risico, maar zo laag mogelijk</option><option value="met-eigen-risico-maar-zo-hoog-mogelijk">Met eigen risico, maar zo hoog mogelijk</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="own_risk_non_ahb" class="control-label">Vrijwillig eigen risico</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="own_risk_non_ahb" name="own_risk_non_ahb"><option value="geen-eigen-risico-of-zo-laag-mogelijk">Geen eigen risico of zo laag mogelijk</option><option value="met-eigen-risico-maar-zo-laag-mogelijk">Met eigen risico, maar zo laag mogelijk</option><option value="met-eigen-risico-maar-zo-hoog-mogelijk">Met eigen risico, maar zo hoog mogelijk</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="purchase_value_insured_period" class="control-label">Aanschafwaarderegeling of -garantie</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="purchase_value_insured_period" name="purchase_value_insured_period"><option value="nee">Nee</option><option value="aankoopwaarde1jaar">1 jaar</option><option value="aankoopwaarde2jaar">2 jaar</option><option value="aankoopwaarde3jaar">3 jaar</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="new_value_insured_period" class="control-label">Nieuwwaarderegeling of -garantie</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="new_value_insured_period" name="new_value_insured_period"><option value="nee">Nee</option><option value="standaard1jaar">1 jaar</option><option value="nieuwwaarde2jaar">2 jaar</option><option value="nieuwwaarde3jaar">3 jaar</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-12 col-md-12 col-xs-12">
<div class="row">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="extended_coverages[]" class="control-label">Aanvullende dekkingen:</label>
</div>
</div>
<div class="row">
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_ovi-laag" name="extended_coverages[]" type="checkbox" value="ovi-laag">
<label for="extended_coverages_ovi-laag" class="control-label">OVI Laag</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_ovi-gem" name="extended_coverages[]" type="checkbox" value="ovi-gem">
<label for="extended_coverages_ovi-gem" class="control-label">OVI Gem.</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_ovi-hoog" name="extended_coverages[]" type="checkbox" value="ovi-hoog">
<label for="extended_coverages_ovi-hoog" class="control-label">OVI Hoog</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_svi-standaard" name="extended_coverages[]" type="checkbox" value="svi-standaard">
<label for="extended_coverages_svi-standaard" class="control-label">SVI (Standaard)</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_svi-uitgebreid" name="extended_coverages[]" type="checkbox" value="svi-uitgebreid">
<label for="extended_coverages_svi-uitgebreid" class="control-label">SVI (Uitgebreid)</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_verhaalshulp" name="extended_coverages[]" type="checkbox" value="verhaalshulp">
<label for="extended_coverages_verhaalshulp" class="control-label">Verhaalshulp</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_rechtsbijstand" name="extended_coverages[]" type="checkbox" value="rechtsbijstand">
<label for="extended_coverages_rechtsbijstand" class="control-label">Rechtsbijstand</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_rechtsbijstand-uitgebreid" name="extended_coverages[]" type="checkbox" value="rechtsbijstand-uitgebreid">
<label for="extended_coverages_rechtsbijstand-uitgebreid" class="control-label">Rechtsbijstand uitgebreid</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_pechhulp-nederland" name="extended_coverages[]" type="checkbox" value="pechhulp-nederland">
<label for="extended_coverages_pechhulp-nederland" class="control-label">Pechhulp Nederland</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_pechhulp-europa" name="extended_coverages[]" type="checkbox" value="pechhulp-europa">
<label for="extended_coverages_pechhulp-europa" class="control-label">Pechhulp Europa</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_max-aanschafwaarde" name="extended_coverages[]" type="checkbox" value="max-aanschafwaarde">
<label for="extended_coverages_max-aanschafwaarde" class="control-label">Max. aanschafwaarde</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_max-nieuwwaarde" name="extended_coverages[]" type="checkbox" value="max-nieuwwaarde">
<label for="extended_coverages_max-nieuwwaarde" class="control-label">Max. nieuwwaarde</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_no-claimbeschermer" name="extended_coverages[]" type="checkbox" value="no-claimbeschermer">
<label for="extended_coverages_no-claimbeschermer" class="control-label">No-claimbeschermer</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_winterstop" name="extended_coverages[]" type="checkbox" value="winterstop">
<label for="extended_coverages_winterstop" class="control-label">Winterstop</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_track-trace" name="extended_coverages[]" type="checkbox" value="track-trace">
<label for="extended_coverages_track-trace" class="control-label">Track Trace</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_vrije-keuze-herstel" name="extended_coverages[]" type="checkbox" value="vrije-keuze-herstel">
<label for="extended_coverages_vrije-keuze-herstel" class="control-label">Vrije keuze herstel</label>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row product-coverages" data-product="11">
<hr>
<div class="panel-group float full-width mb5" id="accordion" role="tablist" aria-multiselectable="true">
<div class="panel panel-default">
<div class="panel-heading" role="tab" id="headingOne">
<h4 class="panel-title">
<a class="collapsed" role="button" data-toggle="collapse" data-parent="#accordion"
href="#collapse_coverages_11"
aria-expanded="false" aria-controls="collapse_coverages_11">
Klik hier voor de dekkingen per maatschappij
</a>
</h4>
</div>
<div id="collapse_coverages_11" class="panel-collapse collapse" role="tabpanel"
aria-labelledby="headingOne">
<div class="panel-body">
<table class="table product-coverages-table">
<thead>
<tr>
<td>Maatschappij</td>
<td>Dekking</td>
</tr>
</thead>
<tbody>
<tr data-company="1">
<td>
<label class="control-label text-left">Unigarant</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="1" autocomplete="off">
<option value="53" data-selected-initially="1"
data-default-score="1"
data-realname="WA" selected>
WA
</option>
</select>
</td>
</tr>
<tr data-company="2">
<td>
<label class="control-label text-left">Nationale Nederlanden</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="2" autocomplete="off">
<option value="53" data-selected-initially="1"
data-default-score="1"
data-realname="WA" selected>
WA
</option>
</select>
</td>
</tr>
<tr data-company="3">
<td>
<label class="control-label text-left">a.s.r.</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="3" autocomplete="off">
<option value="53" data-selected-initially="1"
data-default-score="1"
data-realname="WA" selected>
WA
</option>
</select>
</td>
</tr>
<tr data-company="6">
<td>
<label class="control-label text-left">Reaal</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="6" autocomplete="off">
<option value="53" data-selected-initially="1"
data-default-score="1"
data-realname="WA" selected>
WA
</option>
</select>
</td>
</tr>
<tr data-company="7">
<td>
<label class="control-label text-left">Ansvar Idéa</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="7" autocomplete="off">
<option value="53" data-selected-initially="1"
data-default-score="1"
data-realname="WA" selected>
WA
</option>
</select>
</td>
</tr>
<tr data-company="8">
<td>
<label class="control-label text-left">Klaverblad</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="8" autocomplete="off">
<option value="53" data-selected-initially="1"
data-default-score="1"
data-realname="WA" selected>
WA
</option>
</select>
</td>
</tr>
<tr data-company="17">
<td>
<label class="control-label text-left">Turien en co.</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="17" autocomplete="off">
</select>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
</div>
</div> <div class="row product-risks-wrapper" data-product-id="11" data-product-name="Motor"></div> </div>
</div>
</div>
<div class="col-lg-6 col-md-6 col-sm-12 col-xs-12">
<div class="panel panel-default">
<div class="panel-heading">Regelatige bestuurder</div>
<div class="panel-body">
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_insurer_is_main_driver" class="control-label">Verzekeringnemer is regelmatige bestuurder</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input id="main_driver_insurer_is_main_driver_ja" name="main_driver_insurer_is_main_driver" type="radio" value="ja">
<label for="main_driver_insurer_is_main_driver_ja" class="control-label">ja</label>
<input id="main_driver_insurer_is_main_driver_nee" name="main_driver_insurer_is_main_driver" type="radio" value="nee">
<label for="main_driver_insurer_is_main_driver_nee" class="control-label">nee</label>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_person" class="control-label">Wie is regelmatige bestuurder</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input id="main_driver_person_partner" name="main_driver_person" type="radio" value="partner">
<label for="main_driver_person_partner" class="control-label">Partner</label>
<input id="main_driver_person_anders" name="main_driver_person" type="radio" value="anders">
<label for="main_driver_person_anders" class="control-label">Anders</label>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_birthdate" class="control-label">Geboortedatum</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon"><i class="fa fa-calendar"></i></div>
<input class="form-control" placeholder="dd-mm-jjjj" name="main_driver_birthdate" type="text" id="main_driver_birthdate">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_gender" class="control-label">Geslacht</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input id="main_driver_gender_man" name="main_driver_gender" type="radio" value="man">
<label for="main_driver_gender_man" class="control-label">Man</label>
<input id="main_driver_gender_vrouw" name="main_driver_gender" type="radio" value="vrouw">
<label for="main_driver_gender_vrouw" class="control-label">Vrouw</label>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_postcode" class="control-label">Postcode</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control required" name="main_driver_postcode" type="text" id="main_driver_postcode">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_housenumber" class="control-label">Huisnummer</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control" name="main_driver_housenumber" type="text" id="main_driver_housenumber">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_street" class="control-label">Straat</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control" name="main_driver_street" type="text" id="main_driver_street">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_city" class="control-label">Woonplaats</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control" name="main_driver_city" type="text" id="main_driver_city">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_claim_free_years" class="control-label">Schadevrije jaren</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="main_driver_claim_free_years" name="main_driver_claim_free_years"><option value="-6">-6</option><option value="-5">-5</option><option value="-4">-4</option><option value="-3">-3</option><option value="-2">-2</option><option value="-1">-1</option><option value="0" selected="selected">0</option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="8">8</option><option value="9">9</option><option value="10">10</option><option value="11">11</option><option value="12">12</option><option value="13">13</option><option value="14">14</option><option value="15">15</option><option value="16">16</option><option value="17">17</option><option value="18">18</option><option value="19">19</option><option value="20">20</option><option value="21">21</option><option value="22">22</option><option value="23">23</option><option value="24">24</option><option value="25">25</option><option value="26">26</option><option value="27">27</option><option value="28">28</option><option value="29">29</option><option value="30">30</option><option value="31">31</option><option value="32">32</option><option value="33">33</option><option value="34">34</option><option value="35">35</option><option value="36">36</option><option value="37">37</option><option value="38">38</option><option value="39">39</option><option value="40">40</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="driving_certificate" class="control-label">In bezit van rijvaardigheidscertificaat</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="driving_certificate" name="driving_certificate"><option value="ja">Ja</option><option value="nee">Nee</option></select>
</div>
</div>
</div>
</div>
</div>
</div>
</form>
</div>
</div> </div>
<div role="tabpanel" class="tab-pane" id="tab-motorcycle-oldtimer">
<div class="row tp-wrapper">
<div class="col-sm-12">
<form method="POST" action="https://app.example.net/app/motorcycle-oldtimer/store" accept-charset="UTF-8" class="form-horizontal"><input name="_token" type="hidden" value="LSJ7UMmOiFRd1ufN0UBhb4WuSKg907ZGCfXiwIym">
<div class="row">
<div class="col-lg-6 col-md-6 col-sm-12 col-xs-12">
<div class="panel panel-default">
<div class="panel-heading pull-left col-xs-12">
<div class="pull-left">Oldtimer motorgegevens</div>
</div>
<div class="panel-body">
<p></p>
<br/>
<div class="row">
<div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
<input type="hidden" name="start_date" value="28-03-2018"/>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="license_plate" class="control-label">Kenteken</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control" name="license_plate" type="text" id="license_plate">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="model_code" class="control-label">Meldcode</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control api-fillable" name="model_code" type="text" id="model_code">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="brand" class="control-label">Merk</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control" name="brand" type="text" id="brand">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="model" class="control-label">Model</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control" name="model" type="text" id="model">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="type" class="control-label">Type</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control" name="type" type="text" id="type">
</div>
</div>
<hr/>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="manufacture_year" class="control-label">Bouwjaar en -maand</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control api-fillable" placeholder="jjjj" name="manufacture_year" type="text" id="manufacture_year">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="day_value" class="control-label">Dagwaarde</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control required" name="day_value" type="text" id="day_value">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="appraisal_value" class="control-label">Taxatiewaarde</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control required" name="appraisal_value" type="number" value="0" id="appraisal_value">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="member_fehac" class="control-label">Lid FEHAC</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="member_fehac" name="member_fehac"><option value="ja">Ja</option><option value="nee" selected="selected">Nee</option></select>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="col-lg-6 col-md-6 col-sm-12 col-xs-12">
<div class="panel panel-default">
<div class="panel-heading">Voertuig 1</div>
<div class="panel-body">
<div class="row">
<div class="col-xs-12">
<img class="full-size" src="https://app.example.net/img/car.jpg">
</div>
</div>
<div class="row">
<div class="col-xs-12">
<br/>
<span class="streetview-street"></span> <span class="streetview-housenumber"></span><br/>
<span class="streetview-postalcode"></span> <span class="streetview-city"></span><br/>
<span class="streetview-family-situation"></span>
<hr/>
</div>
</div>
<div class="row form-color-legend"></div> </div>
</div>
</div>
</div>
<div class="row">
<div class="col-lg-6 col-md-6 col-sm-12 col-xs-12">
<div class="panel panel-default">
<div class="panel-heading">Dekking</div>
<div class="panel-body">
<div class="row">
<div class="col-xs-12">
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="bagage_insured" class="control-label">Helm, kleding en bagage</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon">€</div>
<input class="form-control" name="bagage_insured" type="number" value="0" id="bagage_insured">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="mileage" class="control-label">Kilometrage</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon">km</div>
<input class="form-control" name="mileage" type="number" value="12000" id="mileage">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="coverage" class="control-label">Dekking</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input id="coverage_wa" name="coverage" type="radio" value="wa">
<label for="coverage_wa" class="control-label">WA</label>
<input id="coverage_beperkt-casco" name="coverage" type="radio" value="beperkt-casco">
<label for="coverage_beperkt-casco" class="control-label">Beperkt casco</label>
<input id="coverage_volledig-casco" checked="checked" name="coverage" type="radio" value="volledig-casco">
<label for="coverage_volledig-casco" class="control-label">Volledig casco</label>
<input id="coverage_verschillend-per-maatschappij" name="coverage" type="radio" value="verschillend-per-maatschappij">
<label for="coverage_verschillend-per-maatschappij" class="control-label">Verschillend per maatschappij</label>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="own_risk_ahb" class="control-label">Eigen risico</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="own_risk_ahb" name="own_risk_ahb"><option value="geen-eigen-risico-of-zo-laag-mogelijk">Geen eigen risico of zo laag mogelijk</option><option value="met-eigen-risico-maar-zo-laag-mogelijk">Met eigen risico, maar zo laag mogelijk</option><option value="met-eigen-risico-maar-zo-hoog-mogelijk">Met eigen risico, maar zo hoog mogelijk</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-12 col-md-12 col-xs-12">
<div class="row">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="extended_coverages[]" class="control-label">Aanvullende dekkingen:</label>
</div>
</div>
<div class="row">
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_ovi-laag" name="extended_coverages[]" type="checkbox" value="ovi-laag">
<label for="extended_coverages_ovi-laag" class="control-label">OVI Laag</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_ovi-gem" name="extended_coverages[]" type="checkbox" value="ovi-gem">
<label for="extended_coverages_ovi-gem" class="control-label">OVI Gem.</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_ovi-hoog" name="extended_coverages[]" type="checkbox" value="ovi-hoog">
<label for="extended_coverages_ovi-hoog" class="control-label">OVI Hoog</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_svi-standaard" name="extended_coverages[]" type="checkbox" value="svi-standaard">
<label for="extended_coverages_svi-standaard" class="control-label">SVI (Standaard)</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_svi-uitgebreid" name="extended_coverages[]" type="checkbox" value="svi-uitgebreid">
<label for="extended_coverages_svi-uitgebreid" class="control-label">SVI (Uitgebreid)</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_verhaalshulp" name="extended_coverages[]" type="checkbox" value="verhaalshulp">
<label for="extended_coverages_verhaalshulp" class="control-label">Verhaalshulp</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_rechtsbijstand" name="extended_coverages[]" type="checkbox" value="rechtsbijstand">
<label for="extended_coverages_rechtsbijstand" class="control-label">Rechtsbijstand</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_rechtsbijstand-uitgebreid" name="extended_coverages[]" type="checkbox" value="rechtsbijstand-uitgebreid">
<label for="extended_coverages_rechtsbijstand-uitgebreid" class="control-label">Rechtsbijstand uitgebreid</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_pechhulp-nederland" name="extended_coverages[]" type="checkbox" value="pechhulp-nederland">
<label for="extended_coverages_pechhulp-nederland" class="control-label">Pechhulp Nederland</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_pechhulp-europa" name="extended_coverages[]" type="checkbox" value="pechhulp-europa">
<label for="extended_coverages_pechhulp-europa" class="control-label">Pechhulp Europa</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_max-aanschafwaarde" name="extended_coverages[]" type="checkbox" value="max-aanschafwaarde">
<label for="extended_coverages_max-aanschafwaarde" class="control-label">Max. aanschafwaarde</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_max-nieuwwaarde" name="extended_coverages[]" type="checkbox" value="max-nieuwwaarde">
<label for="extended_coverages_max-nieuwwaarde" class="control-label">Max. nieuwwaarde</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_no-claimbeschermer" name="extended_coverages[]" type="checkbox" value="no-claimbeschermer">
<label for="extended_coverages_no-claimbeschermer" class="control-label">No-claimbeschermer</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_winterstop" name="extended_coverages[]" type="checkbox" value="winterstop">
<label for="extended_coverages_winterstop" class="control-label">Winterstop</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_track-trace" name="extended_coverages[]" type="checkbox" value="track-trace">
<label for="extended_coverages_track-trace" class="control-label">Track Trace</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="extended_coverages_vrije-keuze-herstel" name="extended_coverages[]" type="checkbox" value="vrije-keuze-herstel">
<label for="extended_coverages_vrije-keuze-herstel" class="control-label">Vrije keuze herstel</label>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="row product-coverages" data-product="12">
<hr>
<div class="panel-group float full-width mb5" id="accordion" role="tablist" aria-multiselectable="true">
<div class="panel panel-default">
<div class="panel-heading" role="tab" id="headingOne">
<h4 class="panel-title">
<a class="collapsed" role="button" data-toggle="collapse" data-parent="#accordion"
href="#collapse_coverages_12"
aria-expanded="false" aria-controls="collapse_coverages_12">
Klik hier voor de dekkingen per maatschappij
</a>
</h4>
</div>
<div id="collapse_coverages_12" class="panel-collapse collapse" role="tabpanel"
aria-labelledby="headingOne">
<div class="panel-body">
<table class="table product-coverages-table">
<thead>
<tr>
<td>Maatschappij</td>
<td>Dekking</td>
</tr>
</thead>
<tbody>
<tr data-company="1">
<td>
<label class="control-label text-left">Unigarant</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="1" autocomplete="off">
</select>
</td>
</tr>
<tr data-company="2">
<td>
<label class="control-label text-left">Nationale Nederlanden</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="2" autocomplete="off">
</select>
</td>
</tr>
<tr data-company="3">
<td>
<label class="control-label text-left">a.s.r.</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="3" autocomplete="off">
<option value="105" data-selected-initially="1"
data-default-score="4"
data-realname="WA" selected>
WA
</option>
</select>
</td>
</tr>
<tr data-company="6">
<td>
<label class="control-label text-left">Reaal</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="6" autocomplete="off">
</select>
</td>
</tr>
<tr data-company="7">
<td>
<label class="control-label text-left">Ansvar Idéa</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="7" autocomplete="off">
</select>
</td>
</tr>
<tr data-company="8">
<td>
<label class="control-label text-left">Klaverblad</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="8" autocomplete="off">
</select>
</td>
</tr>
<tr data-company="17">
<td>
<label class="control-label text-left">Turien en co.</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="17" autocomplete="off">
</select>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
</div>
</div> <div class="row product-risks-wrapper" data-product-id="12" data-product-name="Oldtimer motor"></div> </div>
</div>
</div>
<div class="col-lg-6 col-md-6 col-sm-12 col-xs-12">
<div class="panel panel-default">
<div class="panel-heading">Regelatige bestuurder</div>
<div class="panel-body">
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_insurer_is_main_driver" class="control-label">Verzekeringnemer is regelmatige bestuurder</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input id="main_driver_insurer_is_main_driver_ja" name="main_driver_insurer_is_main_driver" type="radio" value="ja">
<label for="main_driver_insurer_is_main_driver_ja" class="control-label">ja</label>
<input id="main_driver_insurer_is_main_driver_nee" name="main_driver_insurer_is_main_driver" type="radio" value="nee">
<label for="main_driver_insurer_is_main_driver_nee" class="control-label">nee</label>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_person" class="control-label">Wie is regelmatige bestuurder</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input id="main_driver_person_partner" name="main_driver_person" type="radio" value="partner">
<label for="main_driver_person_partner" class="control-label">Partner</label>
<input id="main_driver_person_anders" name="main_driver_person" type="radio" value="anders">
<label for="main_driver_person_anders" class="control-label">Anders</label>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_birthdate" class="control-label">Geboortedatum</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<div class="input-group">
<div class="input-group-addon"><i class="fa fa-calendar"></i></div>
<input class="form-control" placeholder="dd-mm-jjjj" name="main_driver_birthdate" type="text" id="main_driver_birthdate">
</div>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_gender" class="control-label">Geslacht</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input id="main_driver_gender_man" name="main_driver_gender" type="radio" value="man">
<label for="main_driver_gender_man" class="control-label">Man</label>
<input id="main_driver_gender_vrouw" name="main_driver_gender" type="radio" value="vrouw">
<label for="main_driver_gender_vrouw" class="control-label">Vrouw</label>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_postcode" class="control-label">Postcode</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control required" name="main_driver_postcode" type="text" id="main_driver_postcode">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_housenumber" class="control-label">Huisnummer</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control" name="main_driver_housenumber" type="text" id="main_driver_housenumber">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_street" class="control-label">Straat</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control" name="main_driver_street" type="text" id="main_driver_street">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_city" class="control-label">Woonplaats</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<input class="form-control" name="main_driver_city" type="text" id="main_driver_city">
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="main_driver_claim_free_years" class="control-label">Schadevrije jaren</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="main_driver_claim_free_years" name="main_driver_claim_free_years"><option value="-6">-6</option><option value="-5">-5</option><option value="-4">-4</option><option value="-3">-3</option><option value="-2">-2</option><option value="-1">-1</option><option value="0" selected="selected">0</option><option value="1">1</option><option value="2">2</option><option value="3">3</option><option value="4">4</option><option value="5">5</option><option value="6">6</option><option value="7">7</option><option value="8">8</option><option value="9">9</option><option value="10">10</option><option value="11">11</option><option value="12">12</option><option value="13">13</option><option value="14">14</option><option value="15">15</option><option value="16">16</option><option value="17">17</option><option value="18">18</option><option value="19">19</option><option value="20">20</option><option value="21">21</option><option value="22">22</option><option value="23">23</option><option value="24">24</option><option value="25">25</option><option value="26">26</option><option value="27">27</option><option value="28">28</option><option value="29">29</option><option value="30">30</option><option value="31">31</option><option value="32">32</option><option value="33">33</option><option value="34">34</option><option value="35">35</option><option value="36">36</option><option value="37">37</option><option value="38">38</option><option value="39">39</option><option value="40">40</option></select>
</div>
</div>
</div>
</div>
</div>
</div>
</form>
</div>
</div> </div>
<div role="tabpanel" class="tab-pane" id="tab-responsibility">
<div class="row tp-wrapper">
<div class="col-sm-12">
<form method="POST" action="https://app.example.net/app/responsibility/store" accept-charset="UTF-8" class="form-horizontal"><input name="_token" type="hidden" value="LSJ7UMmOiFRd1ufN0UBhb4WuSKg907ZGCfXiwIym">
<div class="row">
<div class="col-lg-8 col-md-8 col-sm-12 col-xs-12">
<div class="panel panel-default">
<div class="panel-heading pull-left col-xs-12">
<div class="pull-left">Aansprakelijkheid</div>
</div>
<div class="panel-body">
<p></p>
<br/>
<div class="row">
<div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
<input type="hidden" name="start_date" value="28-03-2018"/>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="insured_amount" class="control-label">Verzekerd bedrag</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="insured_amount" name="insured_amount"><option value="2500000" selected="selected">€2.500.000</option><option value="1000000">€1.000.000</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="hunter_risk_insured" class="control-label">Jagersrisico meeverzekeren</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="hunter_risk_insured" name="hunter_risk_insured"><option value="nee" selected="selected">Nee</option><option value="ja">Ja</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="claim_service" class="control-label">Verhaalsservice</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="claim_service" name="claim_service"><option value="nee" selected="selected">Nee</option><option value="ja">Ja</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="rent_second_house" class="control-label">Verhuur 2e woning</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="rent_second_house" name="rent_second_house"><option value="ja">Ja</option><option value="nee" selected="selected">Nee</option></select>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="panel panel-default">
<div class="panel-heading">Risico's en voorwaarden aansprakelijkheid</div>
<div class="panel-body">
<div class="row">
<div class="col-xs-12">
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<button type="button" class="btn btn-default btn-xs pull-right ml5" data-toggle="modal" data-target="#responibility-own-risk-modal"><i class="fa fa-info-circle"></i></button>
<label for="own_risk" class="control-label">Eigen risico’s</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="own_risk" name="own_risk"><option value="geen-eigen-risico-of-zo-laag-mogelijk" selected="selected">Geen eigen risico of zo laag mogelijk</option><option value="met-eigen-risico-maar-zo-laag-mogelijk">Met eigen risico, maar zo laag mogelijk</option><option value="met-eigen-risico-maar-zo-hoog-mogelijk">Met eigen risico, maar zo hoog mogelijk</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="own_risk_children" class="control-label">Eigen risico kinderen</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="own_risk_children" name="own_risk_children"><option value="nee" selected="selected">Nee</option><option value="ja">Ja</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="own_risk_animals" class="control-label">Eigen risico dieren</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="own_risk_animals" name="own_risk_animals"><option value="nee" selected="selected">Nee</option><option value="ja">Ja</option></select>
</div>
</div>
<div class="row product-coverages" data-product="2">
<hr>
<div class="panel-group float full-width mb5" id="accordion" role="tablist" aria-multiselectable="true">
<div class="panel panel-default">
<div class="panel-heading" role="tab" id="headingOne">
<h4 class="panel-title">
<a class="collapsed" role="button" data-toggle="collapse" data-parent="#accordion"
href="#collapse_coverages_2"
aria-expanded="false" aria-controls="collapse_coverages_2">
Klik hier voor de dekkingen per maatschappij
</a>
</h4>
</div>
<div id="collapse_coverages_2" class="panel-collapse collapse" role="tabpanel"
aria-labelledby="headingOne">
<div class="panel-body">
<table class="table product-coverages-table">
<thead>
<tr>
<td>Maatschappij</td>
<td>Dekking</td>
</tr>
</thead>
<tbody>
<tr data-company="1">
<td>
<label class="control-label text-left">Unigarant</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="1" autocomplete="off">
<option value="17" data-selected-initially="1"
data-default-score="1"
data-realname="€2.500.000" selected>
€2.500.000
</option>
</select>
</td>
</tr>
<tr data-company="2">
<td>
<label class="control-label text-left">Nationale Nederlanden</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="2" autocomplete="off">
<option value="15" data-selected-initially="1"
data-default-score="1"
data-realname="€1.000.000" selected>
€1.000.000
</option>
<option value="17" data-selected-initially="0"
data-default-score="1"
data-realname="€2.500.000" >
€2.500.000
</option>
</select>
</td>
</tr>
<tr data-company="3">
<td>
<label class="control-label text-left">a.s.r.</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="3" autocomplete="off">
<option value="16" data-selected-initially="1"
data-default-score="1"
data-realname="€1.250.000" selected>
€1.250.000
</option>
<option value="17" data-selected-initially="0"
data-default-score="1"
data-realname="€2.500.000" >
€2.500.000
</option>
</select>
</td>
</tr>
<tr data-company="6">
<td>
<label class="control-label text-left">Reaal</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="6" autocomplete="off">
<option value="16" data-selected-initially="1"
data-default-score="1"
data-realname="€1.250.000" selected>
€1.250.000
</option>
<option value="17" data-selected-initially="0"
data-default-score="1"
data-realname="€2.500.000" >
€2.500.000
</option>
</select>
</td>
</tr>
<tr data-company="7">
<td>
<label class="control-label text-left">Ansvar Idéa</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="7" autocomplete="off">
<option value="18" data-selected-initially="1"
data-default-score="1"
data-realname="€1.250.000 incl. RB + motorijtuigen" selected>
€1.250.000 incl. RB + motorijtuigen
</option>
<option value="19" data-selected-initially="0"
data-default-score="1"
data-realname="€2.500.000 incl. RB + motorijtuigen" >
€2.500.000 incl. RB + motorijtuigen
</option>
<option value="20" data-selected-initially="0"
data-default-score="1"
data-realname="€1.250.000 incl. RB - motorijtuigen" >
€1.250.000 incl. RB - motorijtuigen
</option>
<option value="21" data-selected-initially="0"
data-default-score="1"
data-realname="€2.500.000 incl. RB - motorijtuigen" >
€2.500.000 incl. RB - motorijtuigen
</option>
</select>
</td>
</tr>
<tr data-company="8">
<td>
<label class="control-label text-left">Klaverblad</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="8" autocomplete="off">
<option value="16" data-selected-initially="1"
data-default-score="1"
data-realname="€1.250.000" selected>
€1.250.000
</option>
<option value="17" data-selected-initially="0"
data-default-score="1"
data-realname="€2.500.000" >
€2.500.000
</option>
</select>
</td>
</tr>
<tr data-company="17">
<td>
<label class="control-label text-left">Turien en co.</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="17" autocomplete="off">
<option value="17" data-selected-initially="1"
data-default-score="1"
data-realname="€2.500.000" selected>
€2.500.000
</option>
</select>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
</div>
</div> <div class="row product-risks-wrapper" data-product-id="2" data-product-name="Aansprakelijkheid"></div> </div>
</div>
</div>
</div>
</div>
<div class="col-lg-4 col-md-4 col-sm-12 col-xs-12">
<div class="panel panel-default streetview-panel">
<div class="panel-heading">Streetview</div>
<div class="panel-body">
<div class="row">
<div class="col-xs-12">
<img class="housephoto full-size">
</div>
</div>
<div class="row">
<div class="col-xs-12">
<br/>
<span class="streetview-street"></span> <span class="streetview-housenumber"></span><br/>
<span class="streetview-postalcode"></span> <span class="streetview-city"></span><br/>
<span class="streetview-family-situation"></span>
<hr/>
</div>
</div>
<div class="row form-color-legend"></div> </div>
</div>
</div>
</div>
</form>
</div>
</div> </div>
<div role="tabpanel" class="tab-pane" id="tab-legal-aid">
<div class="row tp-wrapper">
<div class="col-sm-12">
<form method="POST" action="https://app.example.net/app/legalaid/store" accept-charset="UTF-8" class="form-horizontal"><input name="_token" type="hidden" value="LSJ7UMmOiFRd1ufN0UBhb4WuSKg907ZGCfXiwIym">
<div class="row">
<div class="col-lg-8 col-md-8 col-sm-12 col-xs-12">
<div class="panel panel-default">
<div class="panel-heading pull-left col-xs-12">
<div class="pull-left">Rechtsbijstand</div>
</div>
<div class="panel-body">
<p></p>
<br/>
<div class="row">
<div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
<input type="hidden" name="start_date" value="28-03-2018"/>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="cover_area" class="control-label">Dekkingsgebied</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="cover_area" name="cover_area"><option value="nederland" selected="selected">Nederland</option><option value="europa">Europa</option><option value="wereld">Wereld</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="occupier_capacity" class="control-label">Hoedanigheid bewoner</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="occupier_capacity" name="occupier_capacity"><option value="huurder" selected="selected">Huurder</option><option value="huiseigenaar">Huiseigenaar</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="coverages[]" class="control-label">Dekkingen</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7 inputinlabel">
<div class="row">
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="coverages_verkeersrechtsbijstand-excl-motorrijtuigen" name="coverages[]" type="checkbox" value="verkeersrechtsbijstand-excl-motorrijtuigen">
<label for="coverages_verkeersrechtsbijstand-excl-motorrijtuigen" class="control-label">Verkeersrechtsbijstand excl. motorrijtuigen</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="coverages_verkeersrechtsbijstand-incl-motorrijtuigen" name="coverages[]" type="checkbox" value="verkeersrechtsbijstand-incl-motorrijtuigen">
<label for="coverages_verkeersrechtsbijstand-incl-motorrijtuigen" class="control-label">Verkeersrechtsbijstand incl. motorrijtuigen</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="coverages_consument" name="coverages[]" type="checkbox" value="consument">
<label for="coverages_consument" class="control-label">Consument</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="coverages_medisch" name="coverages[]" type="checkbox" value="medisch">
<label for="coverages_medisch" class="control-label">Medisch</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="coverages_wonen" name="coverages[]" type="checkbox" value="wonen">
<label for="coverages_wonen" class="control-label">Wonen</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="coverages_werk" name="coverages[]" type="checkbox" value="werk">
<label for="coverages_werk" class="control-label">Werk</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="coverages_inkomen" name="coverages[]" type="checkbox" value="inkomen">
<label for="coverages_inkomen" class="control-label">Inkomen</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="coverages_erfrecht" name="coverages[]" type="checkbox" value="erfrecht">
<label for="coverages_erfrecht" class="control-label">Erfrecht</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="coverages_fiscaalvermogen" name="coverages[]" type="checkbox" value="fiscaalvermogen">
<label for="coverages_fiscaalvermogen" class="control-label">Fiscaal/vermogen</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="coverages_scheidingsmediation" name="coverages[]" type="checkbox" value="scheidingsmediation">
<label for="coverages_scheidingsmediation" class="control-label">Scheidingsmediation</label>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="panel panel-default">
<div class="panel-heading">Risico's en voorwaarden rechtsbijstand</div>
<div class="panel-body">
<div class="row product-coverages" data-product="5">
<hr>
<div class="panel-group float full-width mb5" id="accordion" role="tablist" aria-multiselectable="true">
<div class="panel panel-default">
<div class="panel-heading" role="tab" id="headingOne">
<h4 class="panel-title">
<a class="collapsed" role="button" data-toggle="collapse" data-parent="#accordion"
href="#collapse_coverages_5"
aria-expanded="false" aria-controls="collapse_coverages_5">
Klik hier voor de dekkingen per maatschappij
</a>
</h4>
</div>
<div id="collapse_coverages_5" class="panel-collapse collapse" role="tabpanel"
aria-labelledby="headingOne">
<div class="panel-body">
<table class="table product-coverages-table">
<thead>
<tr>
<td>Maatschappij</td>
<td>Dekking</td>
</tr>
</thead>
<tbody>
<tr data-company="1">
<td>
<label class="control-label text-left">Unigarant</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="1" autocomplete="off">
<option value="40" data-selected-initially="1"
data-default-score="1"
data-realname="Default" selected>
Default
</option>
<option value="49" data-selected-initially="0"
data-default-score="1"
data-realname="Consument en Wonen" >
Consument en Wonen
</option>
<option value="50" data-selected-initially="0"
data-default-score="1"
data-realname="Wonen" >
Wonen
</option>
<option value="51" data-selected-initially="0"
data-default-score="1"
data-realname="Consument" >
Consument
</option>
</select>
</td>
</tr>
<tr data-company="2">
<td>
<label class="control-label text-left">Nationale Nederlanden</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="2" autocomplete="off">
<option value="40" data-selected-initially="1"
data-default-score="1"
data-realname="Default" selected>
Default
</option>
<option value="49" data-selected-initially="0"
data-default-score="1"
data-realname="Consument en Wonen" >
Consument en Wonen
</option>
<option value="50" data-selected-initially="0"
data-default-score="1"
data-realname="Wonen" >
Wonen
</option>
<option value="51" data-selected-initially="0"
data-default-score="1"
data-realname="Consument" >
Consument
</option>
</select>
</td>
</tr>
<tr data-company="3">
<td>
<label class="control-label text-left">a.s.r.</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="3" autocomplete="off">
<option value="40" data-selected-initially="1"
data-default-score="1"
data-realname="Default" selected>
Default
</option>
<option value="49" data-selected-initially="0"
data-default-score="1"
data-realname="Consument en Wonen" >
Consument en Wonen
</option>
<option value="50" data-selected-initially="0"
data-default-score="1"
data-realname="Wonen" >
Wonen
</option>
<option value="51" data-selected-initially="0"
data-default-score="1"
data-realname="Consument" >
Consument
</option>
</select>
</td>
</tr>
<tr data-company="6">
<td>
<label class="control-label text-left">Reaal</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="6" autocomplete="off">
<option value="40" data-selected-initially="1"
data-default-score="1"
data-realname="Default" selected>
Default
</option>
<option value="49" data-selected-initially="0"
data-default-score="1"
data-realname="Consument en Wonen" >
Consument en Wonen
</option>
<option value="50" data-selected-initially="0"
data-default-score="1"
data-realname="Wonen" >
Wonen
</option>
<option value="51" data-selected-initially="0"
data-default-score="1"
data-realname="Consument" >
Consument
</option>
</select>
</td>
</tr>
<tr data-company="7">
<td>
<label class="control-label text-left">Ansvar Idéa</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="7" autocomplete="off">
<option value="40" data-selected-initially="1"
data-default-score="1"
data-realname="Default" selected>
Default
</option>
<option value="49" data-selected-initially="0"
data-default-score="1"
data-realname="Consument en Wonen" >
Consument en Wonen
</option>
<option value="50" data-selected-initially="0"
data-default-score="1"
data-realname="Wonen" >
Wonen
</option>
<option value="51" data-selected-initially="0"
data-default-score="1"
data-realname="Consument" >
Consument
</option>
</select>
</td>
</tr>
<tr data-company="8">
<td>
<label class="control-label text-left">Klaverblad</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="8" autocomplete="off">
<option value="40" data-selected-initially="1"
data-default-score="1"
data-realname="Default" selected>
Default
</option>
<option value="49" data-selected-initially="0"
data-default-score="1"
data-realname="Consument en Wonen" >
Consument en Wonen
</option>
<option value="50" data-selected-initially="0"
data-default-score="1"
data-realname="Wonen" >
Wonen
</option>
<option value="51" data-selected-initially="0"
data-default-score="1"
data-realname="Consument" >
Consument
</option>
</select>
</td>
</tr>
<tr data-company="17">
<td>
<label class="control-label text-left">Turien en co.</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="17" autocomplete="off">
</select>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
</div>
</div> <div class="row product-risks-wrapper" data-product-id="5" data-product-name="Rechtsbijstand"></div> </div>
</div>
</div>
<div class="col-lg-4 col-md-4 col-sm-12 col-xs-12">
<div class="panel panel-default streetview-panel">
<div class="panel-heading">Streetview</div>
<div class="panel-body">
<div class="row">
<div class="col-xs-12">
<img class="housephoto full-size">
</div>
</div>
<div class="row">
<div class="col-xs-12">
<br/>
<span class="streetview-street"></span> <span class="streetview-housenumber"></span><br/>
<span class="streetview-postalcode"></span> <span class="streetview-city"></span><br/>
<span class="streetview-family-situation"></span>
<hr/>
</div>
</div>
<div class="row form-color-legend"></div> </div>
</div>
</div>
</div>
</form>
</div>
</div> </div>
<div role="tabpanel" class="tab-pane" id="tab-accident-insurance">
<div class="row tp-wrapper">
<div class="col-sm-12">
<form method="POST" action="https://app.example.net/app/accidentinsurance/store" accept-charset="UTF-8" class="form-horizontal"><input name="_token" type="hidden" value="LSJ7UMmOiFRd1ufN0UBhb4WuSKg907ZGCfXiwIym">
<div class="row">
<div class="col-lg-8 col-md-8 col-sm-12 col-xs-12">
<div class="panel panel-default">
<div class="panel-heading pull-left col-xs-12">
<div class="pull-left">Ongevallenverzekering</div>
</div>
<div class="panel-body">
<p></p>
<br/>
<div class="row">
<div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
<input type="hidden" name="start_date" value="28-03-2018"/>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="who_insured" class="control-label">Wie verzekeren</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="who_insured" name="who_insured"><option value="single_without_children">Alleenstaande zonder kinderen</option><option value="single_with_children">Alleenstaande met kinderen</option><option value="family_without_children">Gezin zonder kinderen</option><option value="family_with_children">Gezin met kinderen</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="death_insured_amount" class="control-label">Bij overlijden</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="death_insured_amount" name="death_insured_amount"><option value="standaard-verzekerde-bedragen">Standaard verzekerde bedragen</option><option value="lage-verzekerde-bedragen">Lage verzekerde bedragen</option><option value="hoge-verzekerde-bedragen">Hoge verzekerde bedragen</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="disability_insured_amount" class="control-label">Bij blijvende invaliditeit</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="disability_insured_amount" name="disability_insured_amount"><option value="standaard-verzekerde-bedragen">Standaard verzekerde bedragen</option><option value="lage-verzekerde-bedragen">Lage verzekerde bedragen</option><option value="hoge-verzekerde-bedragen">Hoge verzekerde bedragen</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="job_professional_activity_insured" class="control-label">Beroepswerkzaamheden meeverzekeren</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="job_professional_activity_insured" name="job_professional_activity_insured"><option value="ja">Ja</option><option value="nee">Nee</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="car_passengers_insured" class="control-label">Passagiers auto meeverzekeren</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="car_passengers_insured" name="car_passengers_insured"><option value="ja" selected="selected">Ja</option><option value="nee">Nee</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="motorcycle_passengers_insured" class="control-label">Bijrijders motor meeverzekeren</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="motorcycle_passengers_insured" name="motorcycle_passengers_insured"><option value="ja">Ja</option><option value="nee" selected="selected">Nee</option></select>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="panel panel-default">
<div class="panel-heading">Risico's en voorwaarden ongevallen</div>
<div class="panel-body">
<div class="row product-coverages" data-product="6">
<hr>
<div class="panel-group float full-width mb5" id="accordion" role="tablist" aria-multiselectable="true">
<div class="panel panel-default">
<div class="panel-heading" role="tab" id="headingOne">
<h4 class="panel-title">
<a class="collapsed" role="button" data-toggle="collapse" data-parent="#accordion"
href="#collapse_coverages_6"
aria-expanded="false" aria-controls="collapse_coverages_6">
Klik hier voor de dekkingen per maatschappij
</a>
</h4>
</div>
<div id="collapse_coverages_6" class="panel-collapse collapse" role="tabpanel"
aria-labelledby="headingOne">
<div class="panel-body">
<table class="table product-coverages-table">
<thead>
<tr>
<td>Maatschappij</td>
<td>Dekking</td>
</tr>
</thead>
<tbody>
<tr data-company="1">
<td>
<label class="control-label text-left">Unigarant</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="1" autocomplete="off">
<option value="52" data-selected-initially="1"
data-default-score="1"
data-realname="(Gezins)ongevallen" selected>
(Gezins)ongevallen
</option>
</select>
</td>
</tr>
<tr data-company="2">
<td>
<label class="control-label text-left">Nationale Nederlanden</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="2" autocomplete="off">
<option value="52" data-selected-initially="1"
data-default-score="1"
data-realname="(Gezins)ongevallen" selected>
(Gezins)ongevallen
</option>
</select>
</td>
</tr>
<tr data-company="3">
<td>
<label class="control-label text-left">a.s.r.</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="3" autocomplete="off">
<option value="52" data-selected-initially="1"
data-default-score="1"
data-realname="(Gezins)ongevallen" selected>
(Gezins)ongevallen
</option>
</select>
</td>
</tr>
<tr data-company="6">
<td>
<label class="control-label text-left">Reaal</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="6" autocomplete="off">
<option value="52" data-selected-initially="1"
data-default-score="1"
data-realname="(Gezins)ongevallen" selected>
(Gezins)ongevallen
</option>
</select>
</td>
</tr>
<tr data-company="7">
<td>
<label class="control-label text-left">Ansvar Idéa</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="7" autocomplete="off">
<option value="52" data-selected-initially="1"
data-default-score="1"
data-realname="(Gezins)ongevallen" selected>
(Gezins)ongevallen
</option>
</select>
</td>
</tr>
<tr data-company="8">
<td>
<label class="control-label text-left">Klaverblad</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="8" autocomplete="off">
<option value="52" data-selected-initially="1"
data-default-score="1"
data-realname="(Gezins)ongevallen" selected>
(Gezins)ongevallen
</option>
</select>
</td>
</tr>
<tr data-company="17">
<td>
<label class="control-label text-left">Turien en co.</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="17" autocomplete="off">
<option value="52" data-selected-initially="1"
data-default-score="1"
data-realname="(Gezins)ongevallen" selected>
(Gezins)ongevallen
</option>
</select>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
</div>
</div> <div class="row product-risks-wrapper" data-product-id="6" data-product-name="(Gezins)ongevallen"></div> </div>
</div>
</div>
<div class="col-lg-4 col-md-4 col-sm-12 col-xs-12">
<div class="panel panel-default streetview-panel">
<div class="panel-heading">Streetview</div>
<div class="panel-body">
<div class="row">
<div class="col-xs-12">
<img class="housephoto full-size">
</div>
</div>
<div class="row">
<div class="col-xs-12">
<br/>
<span class="streetview-street"></span> <span class="streetview-housenumber"></span><br/>
<span class="streetview-postalcode"></span> <span class="streetview-city"></span><br/>
<span class="streetview-family-situation"></span>
<hr/>
</div>
</div>
<div class="row form-color-legend"></div> </div>
</div>
</div>
</div>
</form>
</div>
</div> </div>
<div role="tabpanel" class="tab-pane" id="tab-travel-and-cancellation">
<div class="row tp-wrapper">
<div class="col-sm-12">
<form method="POST" action="https://app.example.net/app/travelandcancellation/store" accept-charset="UTF-8" class="form-horizontal"><input name="_token" type="hidden" value="LSJ7UMmOiFRd1ufN0UBhb4WuSKg907ZGCfXiwIym">
<div class="row">
<div class="col-lg-8 col-md-8 col-sm-12 col-xs-12">
<div class="panel panel-default">
<div class="panel-heading pull-left col-xs-12">
<div class="pull-left">Doorlopende reis- en/of annuleringsverzekering</div>
</div>
<div class="panel-body">
<p></p>
<br/>
<div class="row">
<div class="col-lg-6 col-md-6 col-sm-12 col-xs-12">
<input type="hidden" name="start_date" value="28-03-2018"/>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="insured_people" class="control-label">Wie verzekeren</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="insured_people" name="insured_people"><option value="single_without_children" selected="selected">Alleenstaande zonder kinderen</option><option value="single_with_children">Alleenstaande met kinderen</option><option value="family_without_children">Gezin zonder kinderen</option><option value="family_with_children">Gezin met kinderen</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="cover_area" class="control-label">Dekkingsgebied</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="cover_area" name="cover_area"><option value="europa" selected="selected">Europa</option><option value="wereld">Wereld</option></select>
</div>
</div>
<div class="form-group">
<div class="col-lg-12 col-md-12 col-xs-12" style="padding-left:42px;">
<div class="row">
<div class="col-lg-4 col-md-4 col-xs-5">
<label for="coverages[]" class="control-label">Dekkingen</label>
</div>
</div>
<div class="row">
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="coverages_persoonlijke-hulp" checked="checked" name="coverages[]" type="checkbox" value="persoonlijke-hulp">
<label for="coverages_persoonlijke-hulp" class="control-label">Persoonlijke hulp</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="coverages_autohulp" name="coverages[]" type="checkbox" value="autohulp">
<label for="coverages_autohulp" class="control-label">Autohulp</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="coverages_calamiteiten--aansprakelijkheid" checked="checked" name="coverages[]" type="checkbox" value="calamiteiten--aansprakelijkheid">
<label for="coverages_calamiteiten--aansprakelijkheid" class="control-label">Calamiteiten / aansprakelijkheid</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="coverages_vervangend-vervoer" name="coverages[]" type="checkbox" value="vervangend-vervoer">
<label for="coverages_vervangend-vervoer" class="control-label">Vervangend vervoer</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="coverages_bagage-zonder-geld" checked="checked" name="coverages[]" type="checkbox" value="bagage-zonder-geld">
<label for="coverages_bagage-zonder-geld" class="control-label">Bagage zonder geld</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="coverages_vervangend-verblijf" name="coverages[]" type="checkbox" value="vervangend-verblijf">
<label for="coverages_vervangend-verblijf" class="control-label">Vervangend verblijf</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="coverages_bagage-met-geld" name="coverages[]" type="checkbox" value="bagage-met-geld">
<label for="coverages_bagage-met-geld" class="control-label">Bagage met geld</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="coverages_wintersport" name="coverages[]" type="checkbox" value="wintersport">
<label for="coverages_wintersport" class="control-label">Wintersport</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="coverages_medische-kosten" checked="checked" name="coverages[]" type="checkbox" value="medische-kosten">
<label for="coverages_medische-kosten" class="control-label">Medische kosten</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="coverages_gevaarlijke-sporten" name="coverages[]" type="checkbox" value="gevaarlijke-sporten">
<label for="coverages_gevaarlijke-sporten" class="control-label">Gevaarlijke sporten</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="coverages_ongevallen" name="coverages[]" type="checkbox" value="ongevallen">
<label for="coverages_ongevallen" class="control-label">Ongevallen</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="coverages_rechtsbijstand" name="coverages[]" type="checkbox" value="rechtsbijstand">
<label for="coverages_rechtsbijstand" class="control-label">Rechtsbijstand</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="coverages_sportuitrusting" name="coverages[]" type="checkbox" value="sportuitrusting">
<label for="coverages_sportuitrusting" class="control-label">Sportuitrusting</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="coverages_reisduur-verlengen" name="coverages[]" type="checkbox" value="reisduur-verlengen">
<label for="coverages_reisduur-verlengen" class="control-label">Reisduur verlengen</label>
</div>
<div class="col-lg-6 col-md-6 col-xs-12 inputinlabel">
<input id="coverages_zakelijke-reis" name="coverages[]" type="checkbox" value="zakelijke-reis">
<label for="coverages_zakelijke-reis" class="control-label">Zakelijke reis</label>
</div>
</div>
</div>
</div>
</div>
<div class="col-lg-6 col-md-6 col-sm-12 col-xs-12">
<div class="form-group">
<div class="col-lg-5 col-md-5 col-xs-5">
<label for="insured_amounts" class="control-label">Dekking annulering</label>
</div>
<div class="col-lg-7 col-md-7 col-xs-7">
<select class="form-control" id="insured_amounts" name="insured_amounts"><option value="geen-dekking" selected="selected">Geen dekking</option><option value="standaard-verzekerde-bedragen">Standaard verzekerde bedragen</option><option value="lage-verzekerde-bedragen">Lage verzekerde bedragen</option><option value="hoge-verzekerde-bedragen">Hoge verzekerde bedragen</option></select>
</div>
</div>
<div id="cancellation-options">
<div class="form-group">
<div class="col-lg-5 col-md-5 col-xs-5">
<label for="guarantee_cancellation" class="control-label">Garantie annulering</label>
</div>
<div class="col-lg-7 col-md-7 col-xs-7">
<input id="guarantee_cancellation_nee" checked="checked" name="guarantee_cancellation" type="radio" value="nee">
<label for="guarantee_cancellation_nee" class="control-label">Nee</label>
<input id="guarantee_cancellation_ja" name="guarantee_cancellation" type="radio" value="ja">
<label for="guarantee_cancellation_ja" class="control-label">Ja</label>
</div>
</div>
<div class="form-group">
<div class="col-lg-5 col-md-5 col-xs-5">
<label for="representative_insured" class="control-label">Zaakwaarnemer</label>
</div>
<div class="col-lg-7 col-md-7 col-xs-7">
<input id="representative_insured_nee" checked="checked" name="representative_insured" type="radio" value="nee">
<label for="representative_insured_nee" class="control-label">Nee</label>
<input id="representative_insured_ja" name="representative_insured" type="radio" value="ja">
<label for="representative_insured_ja" class="control-label">Ja</label>
</div>
</div>
<div class="form-group">
<div class="col-lg-5 col-md-5 col-xs-5 has-info-button">
<button type="button" class="btn btn-default btn-xs pull-right ml5" data-toggle="modal" data-target="#travel-animals-modal"><i class="fa fa-info-circle"></i></button>
<label for="cancellation_animals" class="control-label">Huisdieren</label>
</div>
<div class="col-lg-7 col-md-7 col-xs-7">
<input id="cancellation_animals_nee" checked="checked" name="cancellation_animals" type="radio" value="nee">
<label for="cancellation_animals_nee" class="control-label">Nee</label>
<input id="cancellation_animals_ja" name="cancellation_animals" type="radio" value="ja">
<label for="cancellation_animals_ja" class="control-label">Ja</label>
</div>
</div>
<div class="form-group">
<div class="col-lg-5 col-md-5 col-xs-5 has-info-button">
<button type="button" class="btn btn-default btn-xs pull-right ml5" data-toggle="modal" data-target="#travel-extra-modal"><i class="fa fa-info-circle"></i></button>
<label for="cancellation_extra" class="control-label">Extra annuleringsredenen</label>
</div>
<div class="col-lg-7 col-md-7 col-xs-7">
<input id="cancellation_extra_nee" checked="checked" name="cancellation_extra" type="radio" value="nee">
<label for="cancellation_extra_nee" class="control-label">Nee</label>
<input id="cancellation_extra_ja" name="cancellation_extra" type="radio" value="ja">
<label for="cancellation_extra_ja" class="control-label">Ja</label>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
<div class="panel panel-default">
<div class="panel-heading">Risico's en voorwaarden reis en/of annulering</div>
<div class="panel-body">
<div class="form-group">
<div class="col-lg-4 col-md-4 col-xs-5">
<button type="button" class="btn btn-default btn-xs pull-right ml5" data-toggle="modal" data-target="#travel-own-risk-modal"><i class="fa fa-info-circle"></i></button>
<label for="own_risk" class="control-label">Eigen risico's</label>
</div>
<div class="col-lg-8 col-md-8 col-xs-7">
<select class="form-control" id="own_risk" name="own_risk"><option value="geen-eigen-risico-of-zo-laag-mogelijk" selected="selected">Geen eigen risico of zo laag mogelijk</option><option value="met-eigen-risico-maar-zo-laag-mogelijk">Met eigen risico, maar zo laag mogelijk</option><option value="met-eigen-risico-maar-zo-hoog-mogelijk">Met eigen risico, maar zo hoog mogelijk</option></select>
</div>
</div>
<div class="row product-coverages" data-product="7">
<hr>
<div class="panel-group float full-width mb5" id="accordion" role="tablist" aria-multiselectable="true">
<div class="panel panel-default">
<div class="panel-heading" role="tab" id="headingOne">
<h4 class="panel-title">
<a class="collapsed" role="button" data-toggle="collapse" data-parent="#accordion"
href="#collapse_coverages_7"
aria-expanded="false" aria-controls="collapse_coverages_7">
Klik hier voor de dekkingen per maatschappij
</a>
</h4>
</div>
<div id="collapse_coverages_7" class="panel-collapse collapse" role="tabpanel"
aria-labelledby="headingOne">
<div class="panel-body">
<table class="table product-coverages-table">
<thead>
<tr>
<td>Maatschappij</td>
<td>Dekking</td>
</tr>
</thead>
<tbody>
<tr data-company="1">
<td>
<label class="control-label text-left">Unigarant</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="1" autocomplete="off">
<option value="46" data-selected-initially="1"
data-default-score="1"
data-realname="Doorlopende reis basis (Unigarant)" selected>
Doorlopende reis basis (Unigarant)
</option>
<option value="47" data-selected-initially="0"
data-default-score="1"
data-realname="Doorlopende reis Uitgebreid (Unigarant)" >
Doorlopende reis Uitgebreid (Unigarant)
</option>
</select>
</td>
</tr>
<tr data-company="2">
<td>
<label class="control-label text-left">Nationale Nederlanden</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="2" autocomplete="off">
<option value="39" data-selected-initially="1"
data-default-score="1"
data-realname="Doorlopende reis" selected>
Doorlopende reis
</option>
</select>
</td>
</tr>
<tr data-company="3">
<td>
<label class="control-label text-left">a.s.r.</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="3" autocomplete="off">
<option value="39" data-selected-initially="1"
data-default-score="1"
data-realname="Doorlopende reis" selected>
Doorlopende reis
</option>
</select>
</td>
</tr>
<tr data-company="6">
<td>
<label class="control-label text-left">Reaal</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="6" autocomplete="off">
<option value="39" data-selected-initially="1"
data-default-score="1"
data-realname="Doorlopende reis" selected>
Doorlopende reis
</option>
</select>
</td>
</tr>
<tr data-company="7">
<td>
<label class="control-label text-left">Ansvar Idéa</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="7" autocomplete="off">
<option value="39" data-selected-initially="1"
data-default-score="1"
data-realname="Doorlopende reis" selected>
Doorlopende reis
</option>
</select>
</td>
</tr>
<tr data-company="8">
<td>
<label class="control-label text-left">Klaverblad</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="8" autocomplete="off">
<option value="39" data-selected-initially="1"
data-default-score="1"
data-realname="Doorlopende reis" selected>
Doorlopende reis
</option>
</select>
</td>
</tr>
<tr data-company="17">
<td>
<label class="control-label text-left">Turien en co.</label>
</td>
<td>
<select class="form-control product-insurance-coverage "
data-company="17" autocomplete="off">
<option value="39" data-selected-initially="1"
data-default-score="1"
data-realname="Doorlopende reis" selected>
Doorlopende reis
</option>
</select>
</td>
</tr>
</tbody>
</table>
</div>
</div>
</div>
</div>
</div> <div class="row product-risks-wrapper" data-product-id="7" data-product-name="Reis & annulering"></div> </div>
</div>
</div>
<div class="col-lg-4 col-md-4 col-sm-12 col-xs-12">
<div class="panel panel-default streetview-panel">
<div class="panel-heading">Streetview</div>
<div class="panel-body">
<div class="row">
<div class="col-xs-12">
<img class="housephoto full-size">
</div>
</div>
<div class="row">
<div class="col-xs-12">
<br/>
<span class="streetview-street">De schutstraat</span> <span class="streetview-housenumber">145</span><br/>
<span class="streetview-postalcode">7907 CD</span> <span class="streetview-city">Hoogeveen</span><br/>
<span class="streetview-family-situation">Gezin met kinderen</span>
<hr/>
</div>
</div>
<div class="row form-color-legend"></div> </div>
</div>
</div>
</div>
</form>
</div>
</div> </div>
<div role="tabpanel" class="tab-pane" id="tab-overview">
<div id="results-top" class="row tp-wrapper">
<div class="col-sm-8">
<div class="panel-group" id="accordion" role="tablist" aria-multiselectable="true">
<div class="panel panel-default">
<div class="panel-heading" role="tab" id="headingTwo">
<h4 class="panel-title">
<a class="collapsed" role="button" data-toggle="collapse" data-parent="#accordion"
href="#collapseTwo" aria-expanded="false" aria-controls="collapseTwo">
Gegevens
</a>
</h4>
</div>
<div id="collapseTwo" class="panel-collapse collapse" role="tabpanel"
aria-labelledby="headingTwo">
<div class="panel-body">
Hier komen de gegevens in te staan waarmee gerekend wordt in de onderstaande tabel
</div>
</div>
</div>
</div>
</div>
<div class="col-sm-4">
<div class="panel-group pull-right panel-verzekeraars" role="tablist" aria-multiselectable="true">
<div class="panel panel-default">
<div class="panel-heading" role="tab" id="heading3">
<h4 class="panel-title">
<a class="collapsed" role="button" data-toggle="collapse" data-parent="#panel-verzekeraars"
href="#collapse-filter-1242610" aria-expanded="false" aria-controls="collapse-filter-1242610">
Filter verzekeraars
</a>
</h4>
</div>
<div id="collapse-filter-1242610" class="panel-collapse collapse" role="tabpanel" aria-labelledby="heading3">
<div class="panel-body">
<label>
<input type="checkbox" class="filter-verzekeraars" data-companyname="Unigarant"
value="1" checked /> Unigarant
</label>
<label>
<input type="checkbox" class="filter-verzekeraars" data-companyname="Nationale Nederlanden"
value="2" checked /> Nationale Nederlanden
</label>
<label>
<input type="checkbox" class="filter-verzekeraars" data-companyname="a.s.r."
value="3" checked /> a.s.r.
</label>
<label>
<input type="checkbox" class="filter-verzekeraars" data-companyname="Reaal"
value="6" checked /> Reaal
</label>
<label>
<input type="checkbox" class="filter-verzekeraars" data-companyname="Ansvar Idéa"
value="7" checked /> Ansvar Idéa
</label>
<label>
<input type="checkbox" class="filter-verzekeraars" data-companyname="Klaverblad"
value="8" checked /> Klaverblad
</label>
<label>
<input type="checkbox" class="filter-verzekeraars" data-companyname="Turien en co."
value="17" checked /> Turien en co.
</label>
</div>
</div>
</div>
</div>
<div class="pull-right">
<label for="aantal-verzekeraars">Aantal verzekeraars: </label>
<select id="aantal-verzekeraars" class="amount-companies-select form-control" autocomplete="off">
<option value="3" >3</option>
<option value="4" selected>4</option>
<option value="5" >5</option>
<option value="6" >6</option>
<option value="7" >7</option>
</select>
</div>
<div class="pull-right">
<a class="generate-pdf" href="#" target="_blank"><i class="fa fa-file-pdf-o" aria-hidden="true"></i> </a>
</div>
<div class="pull-right" style="padding-right:20px;">
<label for="d-22">debug</label>
<input id="d-22" type="checkbox" class="" autocomplete="off"/>
<br/>
<label for="p-22">punten</label>
<input id="p-22" type="checkbox" class="" autocomplete="off"/>
</div>
</div>
</div>
<div id="results-wrapper" class="tp-wrapper overview ">
<div id="overview-loader" class="overview-progress progress-loader ">
<div class="overview-loader-inner progress-loader-inner">
<div class="overview-loader-content progress-loader-content">
<h2><span class="mif-android"></span> Even geduld</h2>
<p>Het overzicht wordt samengesteld!</p>
<div id="overview-progressbar" class="meter progress-loader-bar progress-loader-progressbar">
<span></span>
</div>
</div>
</div>
</div>
<div id="results-content" class="hidden ">
</div>
</div>
</div>
<div role="tabpanel" class="tab-pane" id="tab-provision-discounts">
<div class="row tp-wrapper">
<div class="col-lg-12 col-md-12 col-sm-12 col-xs-12">
<div class="panel panel-default">
<div class="panel-heading">Provisies & kortingen</div>
<div class="panel-body">
<div class="panel-group pull-right panel-verzekeraars" role="tablist" aria-multiselectable="true">
<div class="panel panel-default">
<div class="panel-heading" role="tab" id="heading3">
<h4 class="panel-title">
<a class="collapsed" role="button" data-toggle="collapse" data-parent="#panel-verzekeraars"
href="#collapse-filter-6540761" aria-expanded="false" aria-controls="collapse-filter-6540761">
Filter verzekeraars
</a>
</h4>
</div>
<div id="collapse-filter-6540761" class="panel-collapse collapse" role="tabpanel" aria-labelledby="heading3">
<div class="panel-body">
<label>
<input type="checkbox" class="filter-verzekeraars" data-companyname="Unigarant"
value="1" checked /> Unigarant
</label>
<label>
<input type="checkbox" class="filter-verzekeraars" data-companyname="Nationale Nederlanden"
value="2" checked /> Nationale Nederlanden
</label>
<label>
<input type="checkbox" class="filter-verzekeraars" data-companyname="a.s.r."
value="3" checked /> a.s.r.
</label>
<label>
<input type="checkbox" class="filter-verzekeraars" data-companyname="Reaal"
value="6" checked /> Reaal
</label>
<label>
<input type="checkbox" class="filter-verzekeraars" data-companyname="Ansvar Idéa"
value="7" checked /> Ansvar Idéa
</label>
<label>
<input type="checkbox" class="filter-verzekeraars" data-companyname="Klaverblad"
value="8" checked /> Klaverblad
</label>
<label>
<input type="checkbox" class="filter-verzekeraars" data-companyname="Turien en co."
value="17" checked /> Turien en co.
</label>
</div>
</div>
</div>
</div>
<div class="panel-group pull-right panel-provisions-discounts" role="tablist" aria-multiselectable="true">
<div class="panel panel-default">
<div class="panel-heading" role="tab" id="heading3">
<h4 class="panel-title">
<a class="collapsed" role="button" data-toggle="collapse" data-parent="#panel-provisions-discounts"
href="#collapse-filter-4615031" aria-expanded="false" aria-controls="collapse-filter-4615031">
Filter velden
</a>
</h4>
</div>
<div id="collapse-filter-4615031" class="panel-collapse collapse" role="tabpanel" aria-labelledby="heading3">
<div class="panel-body">
<label>
<input type="checkbox" class="filter-provisions-discounts" data-target="bruto_premium_pre_package" autocomplete="off"
value="1" />
Bruto-premie voor pakketkorting
</label>
<label>
<input type="checkbox" class="filter-provisions-discounts" data-target="bruto_premium_post_package" autocomplete="off"
value="1" />
Bruto-premie na pakketkorting
</label>
<label>
<input type="checkbox" class="filter-provisions-discounts" data-target="commercial_discount" autocomplete="off"
value="1" />
Commerciële korting
</label>
<label>
<input type="checkbox" class="filter-provisions-discounts" data-target="extra_provision_discount" autocomplete="off"
value="1" />
Provisie korting
</label>
<label>
<input type="checkbox" class="filter-provisions-discounts" data-target="provision" autocomplete="off"
value="1" checked />
Provisiepercentage
</label>
<label>
<input type="checkbox" class="filter-provisions-discounts" data-target="tax" autocomplete="off"
value="1" checked />
Assurantiebelasting
</label>
<label>
<input type="checkbox" class="filter-provisions-discounts" data-target="netto_premium" autocomplete="off"
value="1" checked />
Totale premies
</label>
</div>
</div>
</div>
</div>
<div id="provisions-discounts-ajax"></div>
<div id="provisions-discounts-loader" class="provisions-discounts-progress progress-loader ">
<div class="provisions-discounts-loader-inner progress-loader-inner">
<div class="provisions-discounts-loader-content progress-loader-content">
<h2><span class="mif-android"></span> Even geduld</h2>
<p>De premies, provisies en kortingen worden voor u berekend!</p>
<div id="provisions-discounts-progressbar" class="meter progress-loader-bar progress-loader-progressbar">
<span></span>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
</div>
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