TravelJoy

Code Fun Travel (Lynette)

SNL Entertainment LLC DBA Code Fun Travel

Insurance Policy

<html>
  <body>
    <form-template>&#13;
	<fields>&#13;
		<field type="header" subtype="h2" label="Primary Applicant"/>&#13;
		<field type="radio-group" required="true" label="Gender" name="gender">&#13;
			<option label="M" value="m">M</option>&#13;
			<option label="F" value="f">F</option>&#13;
			<option label="X" value="x">X</option>&#13;
		</field>&#13;
		<field type="date" required="true" label="Birthday" name="birthday" className="form-control"/>&#13;
		<field type="text" required="true" label="First name" name="first-name" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Last name" name="last-name" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Suffix" name="suffix" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Email" name="email" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Phone number" name="phone-number" subtype="text" className="form-control"/>&#13;
		<field type="header" subtype="h2" label="Address"/>&#13;
		<field type="text" required="true" label="Line 1" name="address-line-1" subtype="text" className="form-control"/>&#13;
		<field type="text" label="Line 2" name="address-line-2" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="City" name="address-city" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="State" name="address-state" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Zip" name="address-zip" subtype="text" className="form-control"/>&#13;
		<field type="text" required="true" label="Country" name="address-country" subtype="text" className="form-control"/>&#13;
		<field type="textarea" label="Applicant #2 (Full Name, Date of Birth, State of Residence) – if applicable." description="Format: John Doe  1/2/1956  VA" placeholder="John Doe  1/2/1956  VA" name="cruiser-2-firstlast-name-dob-vifp-number-state-of-residence-if-applicable" rows="1" className="form-control"/>&#13;
		<field type="textarea" label="Applicant #3 (Full Name, Date of Birth, State of Residence) – if applicable." description="Format: John Doe  1/2/1956  VA" placeholder="John Doe  1/2/1956  VA" name="textarea-1739639226608" rows="1" className="form-control"/>&#13;
		<field type="textarea" label="Applicant #4 (Full Name, Date of Birth, State of Residence) – if applicable." description="Format: John Doe  1/2/1956  VA" placeholder="John Doe  1/2/1956  VA" name="textarea-1739639225346" rows="1" className="form-control"/>&#13;
		<field type="textarea" label="Applicant #5 (Full Name, Date of Birth, State of Residence) – if applicable." description="Format: John Doe  1/2/1956  VA" placeholder="John Doe  1/2/1956  VA" name="textarea-1739639224613" rows="1" className="form-control"/>&#13;
	</fields>&#13;
</form-template>
  </body>
</html>