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reportloss.html
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reportloss.html
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<!DOCTYPE html>
<html lang="en">
<head>
<meta charset="utf-8">
<title>Pradhan Mantri Fasal Bima Yojana</title>
<meta name="viewport" content="width=device-width, initial-scale=1.0">
<meta name="description" content="">
<meta name="author" content="">
<!-- styles -->
<link href="https://fonts.googleapis.com/css?family=Open+Sans:400italic,400,600,700" rel="stylesheet">
<link href="assets/css/bootstrap.css" rel="stylesheet">
<link href="assets/css/bootstrap-responsive.css" rel="stylesheet">
<link href="assets/css/docs.css" rel="stylesheet">
<link href="assets/css/prettyPhoto.css" rel="stylesheet">
<link href="assets/js/google-code-prettify/prettify.css" rel="stylesheet">
<link href="assets/css/style.css" rel="stylesheet">
<link href="assets/color/default.css" rel="stylesheet">
<!-- fav and touch icons -->
<link rel="shortcut icon" href="assets/ico/favicon.ico">
<link rel="apple-touch-icon-precomposed" sizes="144x144" href="assets/ico/apple-touch-icon-144-precomposed.png">
<link rel="apple-touch-icon-precomposed" sizes="114x114" href="assets/ico/apple-touch-icon-114-precomposed.png">
<link rel="apple-touch-icon-precomposed" sizes="72x72" href="assets/ico/apple-touch-icon-72-precomposed.png">
<link rel="apple-touch-icon-precomposed" href="assets/ico/apple-touch-icon-57-precomposed.png">
</head>
<body data-spy="scroll" data-target=".bs-docs-sidebar">
<header>
<!-- Navbar
================================================== -->
<div class="navbar navbar-fixed-top">
<div class="navbar-inner">
<div class="container">
<!-- logo -->
<a class="brand logo" href="index.html"><img src="assets/img/head.png" alt=""></a>
<!-- end logo -->
<!-- top menu -->
<div class="navigation">
<nav>
<ul class="nav topnav">
<li class="dropdown">
<a href="index.html">Home</a>
</li>
<li>
<a href="about.html">About Us</a>
</li>
<li>
<a href="contact.html">Contact</a>
</li>
</ul>
</nav>
</div>
<!-- end menu -->
</div>
</div>
</div>
</header>
<!-- Subhead
================================================== -->
<section id="subintro">
<div class="jumbotron subhead" id="overview">
<div class="container">
<div class="row">
<div class="span12">
<div class="centered">
<h3>REPORT CROP LOSS</h3>
<p>Claim for Insurance!</p>
</div>
</div>
</div>
</div>
</div>
</section>
<form action="" method="post" role="form" class="contactForm" style="margin-left: 300px">
<div class="row">
<div class="span4 form-group">
<select class="form-dropdown validate[required]" id="input_14" name="q14_applyingFor" style="width:370px" data-component="dropdown" required="">
<option value="">Select crop type </option>
<option value="Work 1 "> Rabi </option>
<option value="Work 2"> Kharif </option>
</select>
</div>
<div class="span4 form-group">
<input type="text" name="name" class="form-control" id="name" placeholder="ID" data-rule="minlen:4"
data-msg="Please enter at least 4 chars" />
<div class="validation"></div>
</div>
<div class="span4 form-group">
<input type="text" name="name" class="form-control" id="name" placeholder="State" data-rule="minlen:4"
data-msg="Please enter at least 4 chars" />
<div class="validation"></div>
</div>
<div class="span4 form-group">
<input type="text" name="name" class="form-control" id="name" placeholder="District" data-rule="minlen:4"
data-msg="Please enter at least 4 chars" />
<div class="validation"></div>
</div>
<div class="span4 form-group">
<input type="text" name="name" class="form-control" id="name" placeholder="Area" data-rule="minlen:4"
data-msg="Please enter at least 4 chars" />
<div class="validation"></div>
</div>
<div class="span4 form-group">
<input type="text" name="name" class="form-control" id="name" placeholder="PIN" data-rule="minlen:4"
data-msg="Please enter at least 4 chars" />
<div class="validation"></div>
</div>
<div class="span4 form-group">
<input type="text" name="name" class="form-control" id="name" placeholder="Upload" data-rule="minlen:4" data-msg="Please enter at least 4 chars" />
<div class="validation"></div>
</div>
<div class="span4 form-group">
<input type="text" name="name" class="form-control" id="name" placeholder="Upload" data-rule="minlen:4" data-msg="Please enter at least 4 chars" />
<div class="validation"></div>
</div>
<div class="span8 form-group">
<div class="text-center">
<button class="btn btn-color btn-rounded" type="submit">Submit</button>
</div>
</div>
</div>
</form>
</body>
</html>