Kontakt

Antrag DFA Basis Mitgliedschaft

Versicherungsnehmer

Vorname *

Nachname *

Geburtsdatum *

Versicherungsdauer

42 Tage

Vertragsbeginn *

Kontaktinformationen

Telefonnummer *

E-Mail-Adresse *

Straße *

Postleitzahl *

Stadt *

Bankinformationen

IBAN *

Name des Kontoinhabers, falls abweichend vom Antragsteller

Mitversicherte Personen

Kosten

Versicherungsnehmer

Total

<div class="py-8 grid grid-cols-12 gap-6 person person{0}" data-row="{0}">
    <div class="form-group col-span-12 sm:col-span-3">
      <label for="firstname{0}" class="block text-sm font-medium text-gray-700">Vorname <span class="text-danger">*</span></label>
      <input type="text" name="persons[{0}][firstname]" id="firstname{0}" autocomplete="given-name" class=" bg-gray-100 form-input name-field form-control required mt-1 focus:ring-0 focus:border-none block w-full shadow-sm sm:text-sm border-none rounded-md" required />
    </div>
    <div class="form-group col-span-12 sm:col-span-3">
      <label for="lastname{0}" class="block text-sm font-medium text-gray-700">Nachname <span class="text-danger">*</span></label>
      <input type="text" name="persons[{0}][lastname]" id="lastname{0}" autocomplete="family-name" class=" bg-gray-100 form-input name-field form-control required mt-1 focus:ring-0 focus:border-none block w-full shadow-sm sm:text-sm border-none rounded-md" required />
    </div>
    <div class="form-group col-span-9 sm:col-span-3">
      <label for="birthday{0}" class="block text-sm font-medium text-gray-700">Geburtsdatum <span class="text-danger">*</span></label>
      <input readonly type="text" name="persons[{0}][birthday]" id="birthday{0}" autocomplete="birthday" class="birthday bg-gray-100 form-input form-control required mt-1 focus:ring-0 focus:border-none block w-full shadow-sm sm:text-sm border-none rounded-md" required />
    </div>
    
    <div class="form-group col-span-3 sm:col-span-3">
      <label for="remove{0}" class="block text-sm font-medium">Entfernen</label>
      <input data-row="{0}" id="remove{0}" type="button" class="removePerson transition duration-200 block cursor-pointer border  rounded-full bg-purple-700 shadow w-10 h-10 text-sm font-semibold text-white text-center hover:bg-purple-800 focus:ring-0" value="X">
    </div>

</div>