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IMR_purchase.html
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<!doctype html>
<!--[if lt IE 7]> <html class="no-js lt-ie9 lt-ie8 lt-ie7" lang="en"> <![endif]-->
<!--[if IE 7]> <html class="no-js lt-ie9 lt-ie8" lang="en"> <![endif]-->
<!--[if IE 8]> <html class="no-js lt-ie9" lang="en"> <![endif]-->
<!--[if gt IE 8]><!--> <html class="no-js" lang="en"> <!--<![endif]-->
<head>
<meta charset="utf-8">
<meta http-equiv="X-UA-Compatible" content="IE=edge,chrome=1">
<title>InsureMYRide - Bike Insurance Quote - HTML Prototype v1</title>
<meta name="description" content="">
<meta name="viewport" content="width=device-width">
<link rel="stylesheet" href="css/style.css">
<script src="js/libs/modernizr-2.5.3.min.js"></script>
</head>
<body id="price-page">
<header>
<div class="top ">
<button onclick="location.href='IMR_price.html'"><small>◀</small> Back</button>
<img class="logo" src="http://www.insuremyride.com.au/imr/sites/all/themes/imr/images/insure-my-ride.gif" />
</div>
<div class="bar">
<div class="bar-inner clearfix">
<h1>Bike insurance quote</h1>
<div class="progress">Step 3 of 3</div>
</div>
</div>
</header>
<div id="content" role="main">
<form class="form-purchase" action="IMR_summary.html">
<h2>Personal details</h2>
<fieldset>
<div class="question">
<label for="firstname">First name:</label>
<input id="firstname" type="text" class="hge" />
</div>
<div class="question">
<label for="lastname">Last name:</label>
<input id="lastname" type="text" class="hge" />
</div>
<div class="question">
<label for="dob_d">Date of birth:</label>
<div class="datefield">
<input name="mainrider-dob" id="dob_d" class="day" type="tel" maxlength="2" placeholder="DD" /> /
<input name="mainrider-dob" id="dob_m" class="month" type="tel" maxlength="2" placeholder="MM" />/
<input name="mainrider-dob" id="dob_y" class="year" type="tel" maxlength="4" placeholder="YYYY" />
</div>
</div>
<div class="question">
<label for="phone">Phone number:</label>
<input id="phone" type="tel" class="lge" />
</div>
<div class="question">
<label for="email">Email address:</label>
<input id="email" type="email" class="full" />
<small class="block"><label><input type="checkbox"/> Keep me in the know with promotions and competitions</label></small>
</div>
</fieldset>
<h2>Address details</h2>
<fieldset>
<div class="question">
<label for="propertyname">Property name:</label><small class="optional">(Optional)</small>
<input id="propertyname" type="text" class="full" placeholder="eg. Suncorp Building" />
</div>
<div class="question">
<label for="buildingtype">Building type and Number:</label><small class="optional">(Optional)</small>
<input id="buildingtype" type="text" placeholder="eg. Level" class="half" />
<input id="buildingnum" type="text" placeholder="eg. 15" class="half" />
</div>
<div class="question">
<label for="buildingtype">Street number and Name:</label>
<input id="buildingtype" type="text" placeholder="eg. 447" class="quarter" />
<input id="buildingnum" type="text" placeholder="eg. Collins St." class="threequarter" />
</div>
<div class="question">
<label for="suburbpc">Suburb and Postcode</label>
<input id="suburbpc" type="text" class="full" placeholder="eg. Melbourne 3000" />
</div>
<div class="question">
<label for="state">State</label>
<select id="state">
<option>Please select...</option>
<option>ACT</option>
<option>NSW</option>
<option>VIC</option>
<option>QLD</option>
<option>SA</option>
<option>WA</option>
<option>TAS</option>
<option>NT</option>
</select>
</div>
</fieldset>
<h2>Payment details</h2>
<fieldset>
<div class="question">
<small class="cctype">
<img src="http://www.norcalcleansober.com/Pics/visa_mastercard_logo.gif"/>
Visa & MasterCard accepted
</small>
<label for="cc">Credit card number:</label>
<input id="cc" type="tel" class="lge"/>
</div>
<div class="question">
<label for="ccname">Name on card:</label>
<input id="ccname" type="tel" class="hge"/>
</div>
<div class="question">
<label for="ccmonth">Card expiry date:</label>
<select id="ccmonth">
<option></option>
<option>01</option>
<option>02</option>
<option>03</option>
<option>04</option>
<option>05</option>
<option>06</option>
<option>07</option>
<option>08</option>
<option>09</option>
<option>10</option>
<option>11</option>
<option>12</option>
</select>
<select id="ccyear">
<option></option>
<option>2012</option>
<option>2013</option>
<option>2014</option>
<option>2015</option>
<option>2016</option>
<option>2017</option>
<option>2018</option>
<option>2019</option>
<option>2020</option>
<option>2022</option>
</select>
</div>
</fieldset>
<h2>Final bike details</h2>
<fieldset>
<div class="question horiz">
<div class="horiz-left"><label for="rego">Bike registration number:</label></div>
<div class="horiz-right"><input id="rego" class="med" type="tel" maxlength="7"/></div>
</div>
<div class="question horiz">
<div class="horiz-left"><label for="vin">Vin number:</label></div>
<div class="horiz-right"><input id="vin" class="lge" type="tel" maxlength="16"/></div>
</div>
<div class="question" id="other-riders">
<label>
Add up to 3 other <a href="#?q=5">regular</a> riders of you bike who you would like to cover.
<small>(Optional)</small>
</label>
<div class="sub-question horiz">
<div class="horiz-left">
<label for="name1">Name:</label>
<input id="name1" type="text" class="full" placeholder="Additional rider 1"/>
</div>
<div class="horiz-right">
<label for="rider1-d">Date of birth:</label>
<div class="datefield" >
<input name="rider1-dob" class="day" id="rider1-d" type="tel" maxlength="2" placeholder="DD" />/
<input name="rider1-dob" class="month" id="rider1-m" type="tel" maxlength="2" placeholder="MM" />/
<input name="rider1-dob" class="year" id="rider1-y" type="tel" maxlength="4" placeholder="YYYY" />
</div>
</div>
</div>
<div class="sub-question horiz">
<div class="horiz-left">
<input id="name1" type="text" class="full" placeholder="Additional rider 2"/>
</div>
<div class="horiz-right">
<div class="datefield" >
<input name="rider2-dob" class="day" id="rider1-d" type="tel" maxlength="2" placeholder="DD" /> /
<input name="rider2-dob" class="month" id="rider1-m" type="tel" maxlength="2" placeholder="MM" />/
<input name="rider3-dob" class="year" id="rider1-y" type="tel" maxlength="4" placeholder="YYYY" />
</div>
</div>
</div>
<div class="sub-question horiz">
<div class="horiz-left">
<input id="name1" type="text" class="full" placeholder="Additional rider 3"/>
</div>
<div class="horiz-right">
<div class="datefield" >
<input name="rider3-dob" class="day" id="rider1-d" type="tel" maxlength="2" placeholder="DD" /> /
<input name="rider3-dob" class="month" id="rider1-m" type="tel" maxlength="2" placeholder="MM" />/
<input name="rider3-dob" class="year" id="rider1-y" type="tel" maxlength="4" placeholder="YYYY" />
</div>
</div>
</div>
</div>
</fieldset>
<button class="submit">Confirm & Purchase</button>
</form>
</div>
<script src="js/libs/jquery-1.7.1.min.js"></script>
<script src="js/libs/jquery.autotab-1.1b.js"></script>
<script src="js/script.js"></script>
</body>
</html>