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@ -15,8 +15,9 @@ |
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<input name="claimant_children" value="{{ claimant_children }}" title="claimant_children" hidden /> |
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</div> |
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<div class="question-well"> |
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<h3>Is medical coverage available for the children?</h3> |
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<div class="question-well {% if medical_coverage_available_error %}error{% endif %}"> |
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<h3>Is medical coverage available for the children? {% if medical_coverage_available_error %}{% include 'partials/required.html' %}{% endif %} |
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</h3> |
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<div class="btn-radio-group" data-toggle="buttons"> |
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<label class="btn btn-radio"> |
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{% input_field type="radio" name="medical_coverage_available" autocomplete="off" value="YES" data_target_id="who_plan_is_coverage_under" data_reveal_class="true" data_reveal_target="true" %} Yes |
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@ -28,8 +29,8 @@ |
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</div> |
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</div> |
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<div class="question-well" id="who_plan_is_coverage_under" hidden> |
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<h3>Whose plan is the coverage under?</h3> |
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<div class="question-well {% if whose_plan_is_coverage_under_error %}error{% endif %}" id="who_plan_is_coverage_under" hidden> |
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<h3>Whose plan is the coverage under? {% if whose_plan_is_coverage_under_error %}{% include 'partials/required.html' %}{% endif %}</h3> |
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<p>Please check all that apply:</p> |
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<div class="checkbox-group"> |
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<div class="checkbox"><label>{% input_field type="checkbox" name="whose_plan_is_coverage_under" value="My plan" %} My plan</label></div> |
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@ -37,7 +38,7 @@ |
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</div> |
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</div> |
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<div class="question-well"> |
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<div class="question-well {% if child_support_payments_in_arrears_error %}error{% endif %}"> |
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<h3>Are there any child support payments ( |
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<span class="tooltip-link" |
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data-toggle="tooltip" data-placement="right" data-html="true" |
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@ -47,7 +48,9 @@ |
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"> |
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in arrears <i class="fa fa-question-circle" aria-hidden="true"></i> |
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</span> |
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) that have not been paid (as of today's date) under an existing order or written agreement?</h3> |
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) that have not been paid (as of today's date) under an existing order or written agreement? |
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{% if child_support_payments_in_arrears_error %}{% include 'partials/required.html' %}{% endif %} |
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</h3> |
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<div class="btn-radio-group" data-toggle="buttons"> |
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<label class="btn btn-radio"> |
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{% input_field type="radio" name="child_support_payments_in_arrears" autocomplete="off" value="YES" data_target_id="arrears_amount_question" data_reveal_target="true" %} Yes |
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@ -58,8 +61,8 @@ |
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</label> |
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</div> |
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</div> |
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<div class="question-well" id="arrears_amount_question" hidden> |
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<h3>What is the amount as of today's date?</h3> |
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<div class="question-well {% if child_support_arrears_amount_error %}error{% endif %}" id="arrears_amount_question" hidden> |
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<h3>What is the amount as of today's date? {% if child_support_arrears_amount_error %}{% include 'partials/required.html' %}{% endif %}</h3> |
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<div class="dollar-prefix"> |
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{% money_input_field name="child_support_arrears_amount" class="money positive-float form-control input-narrow" min="0" %} |
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</div> |
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