{"id":1593,"date":"2026-08-20T06:58:41","date_gmt":"2026-08-20T06:58:41","guid":{"rendered":"https:\/\/geminia.co.ke\/dev\/?page_id=1593"},"modified":"2026-08-20T07:08:20","modified_gmt":"2026-08-20T07:08:20","slug":"wiba-form","status":"publish","type":"page","link":"https:\/\/geminia.co.ke\/dev\/wiba-form\/","title":{"rendered":"WIBA Form"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"1593\" class=\"elementor elementor-1593\">\n\t\t\t\t<div class=\"elementor-element elementor-element-a81754b e-con-full e-flex e-con e-parent\" data-id=\"a81754b\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t<div class=\"elementor-element elementor-element-b829a7c elementor-widget elementor-widget-html\" data-id=\"b829a7c\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"html.default\">\n\t\t\t\t\t<div id=\"gwiba\"\r\n     data-endpoint=\"https:\/\/script.google.com\/macros\/s\/AKfycbwVyjSg7Mqig-1H_zbD22rRr4wx2ASb7mtF37F4qXd0J1z0aqVfKdYobQaMVqwF9PTE\/exec\">\r\n\r\n<style>\r\n\/* ---- Fonts & tokens ------------------------------------------------ *\/\r\n@import url('https:\/\/fonts.googleapis.com\/css2?family=Inter:wght@400;500;600;700&family=Poppins:wght@500;600;700&display=swap');\r\n\r\n#gwiba{\r\n  --primary:#3fa6dd;\r\n  --accent:#393680;\r\n  --grad:#3fa6dd;\r\n  --bg:#F8F9FB;\r\n  --card:#FFFFFF;\r\n  --ink:#16283D;\r\n  --muted:#65758B;\r\n  --line:#E6EAF0;\r\n  --line-2:#EDF0F5;\r\n  --ok:#16A34A;\r\n  --err:#E5484D;\r\n  --radius:16px;\r\n  --radius-in:12px;\r\n  --shadow-s:0 1px 2px rgba(16,24,40,.05);\r\n  --shadow-m:0 8px 30px rgba(16,24,40,.08);\r\n  --shadow-btn:0 8px 20px rgba(57,54,128,.28);\r\n\r\n  all:initial;\r\n  display:block;\r\n  box-sizing:border-box;\r\n  font-family:'Inter',system-ui,-apple-system,Segoe UI,Roboto,sans-serif;\r\n  color:var(--ink);\r\n  background:var(--bg);\r\n  padding:28px 16px 48px;\r\n  -webkit-font-smoothing:antialiased;\r\n  line-height:1.55;\r\n}\r\n#gwiba *,#gwiba *::before,#gwiba *::after{box-sizing:border-box;margin:0;padding:0;}\r\n#gwiba button{font-family:inherit;}\r\n\r\n\/* ---- Shell --------------------------------------------------------- *\/\r\n#gwiba .gwiba-shell{max-width:760px;margin:0 auto;}\r\n\r\n\/* ---- Progress ------------------------------------------------------ *\/\r\n#gwiba .gwiba-progress{margin:0 4px 22px;opacity:0;transform:translateY(-6px);\r\n  transition:opacity .4s ease,transform .4s ease;}\r\n#gwiba .gwiba-progress.on{opacity:1;transform:none;}\r\n#gwiba .gwiba-progress-top{display:flex;justify-content:space-between;align-items:baseline;\r\n  margin-bottom:10px;}\r\n#gwiba .gwiba-step-label{font-size:13px;font-weight:600;color:var(--muted);letter-spacing:.01em;}\r\n#gwiba .gwiba-step-name{font-size:13px;font-weight:600;color:var(--primary);}\r\n#gwiba .gwiba-track{height:7px;background:#E9EEF4;border-radius:99px;overflow:hidden;}\r\n#gwiba .gwiba-fill{height:100%;width:0;border-radius:99px;background:var(--grad);\r\n  transition:width .5s cubic-bezier(.4,0,.2,1);}\r\n\r\n\/* ---- Card \/ steps -------------------------------------------------- *\/\r\n#gwiba .gwiba-card{background:var(--card);border:1px solid var(--line-2);\r\n  border-radius:var(--radius);box-shadow:var(--shadow-m);\r\n  padding:36px 34px;position:relative;overflow:hidden;}\r\n#gwiba .gwiba-card::before{content:\"\";position:absolute;top:0;left:0;right:0;height:3px;\r\n  background:var(--grad);z-index:5;}\r\n#gwiba .gwiba-step{display:none;}\r\n#gwiba .gwiba-step.active{display:block;animation:gwibaIn .42s cubic-bezier(.22,.61,.36,1);}\r\n#gwiba .gwiba-step.leaving{animation:gwibaOut .28s ease forwards;}\r\n@keyframes gwibaIn{from{opacity:0;transform:translateY(14px)}to{opacity:1;transform:none}}\r\n@keyframes gwibaOut{to{opacity:0;transform:translateY(-10px)}}\r\n\r\n#gwiba .gwiba-eyebrow{display:inline-flex;align-items:center;gap:7px;font-size:12px;\r\n  font-weight:600;letter-spacing:.06em;text-transform:uppercase;color:var(--accent);\r\n  background:rgba(63,166,221,.09);padding:6px 12px;border-radius:99px;margin-bottom:16px;}\r\n#gwiba h2.gwiba-h{font-family:'Poppins',sans-serif;font-weight:600;font-size:25px;\r\n  line-height:1.25;letter-spacing:-.01em;color:var(--ink);margin-bottom:8px;}\r\n#gwiba .gwiba-sub{color:var(--muted);font-size:15px;margin-bottom:26px;max-width:56ch;}\r\n#gwiba .gwiba-sec{font-family:'Poppins',sans-serif;font-size:12.5px;font-weight:600;\r\n  color:var(--primary);letter-spacing:.03em;text-transform:uppercase;\r\n  margin:26px 0 14px;padding-top:18px;border-top:1px dashed var(--line);}\r\n#gwiba .gwiba-sec:first-of-type{margin-top:0;padding-top:0;border-top:0;}\r\n\r\n\/* ---- Fields -------------------------------------------------------- *\/\r\n#gwiba .gwiba-field{margin-bottom:20px;}\r\n#gwiba .gwiba-grid-2{display:grid;grid-template-columns:1fr 1fr;gap:16px;}\r\n#gwiba .gwiba-grid-3{display:grid;grid-template-columns:1fr 1fr 1fr;gap:16px;}\r\n#gwiba label.gwiba-lab{display:block;font-size:13.5px;font-weight:600;color:var(--ink);\r\n  margin-bottom:8px;}\r\n#gwiba .gwiba-req{color:var(--accent);}\r\n#gwiba .gwiba-hint{font-size:12.5px;color:var(--muted);margin-top:6px;}\r\n#gwiba .gwiba-input,#gwiba .gwiba-select,#gwiba .gwiba-area{\r\n  width:100%;font-family:inherit;font-size:15px;color:var(--ink);\r\n  background:#fff;border:1.5px solid var(--line);border-radius:var(--radius-in);\r\n  padding:13px 15px;transition:border-color .2s,box-shadow .2s,background .2s;}\r\n#gwiba .gwiba-area{resize:vertical;min-height:88px;}\r\n#gwiba .gwiba-input::placeholder,#gwiba .gwiba-area::placeholder{color:#9AA7B7;}\r\n#gwiba .gwiba-input:focus,#gwiba .gwiba-select:focus,#gwiba .gwiba-area:focus{\r\n  outline:none;border-color:var(--accent);box-shadow:0 0 0 4px rgba(63,166,221,.14);}\r\n#gwiba .gwiba-input.err,#gwiba .gwiba-select.err,#gwiba .gwiba-area.err{border-color:var(--err);\r\n  box-shadow:0 0 0 4px rgba(229,72,77,.12);}\r\n#gwiba .gwiba-err{display:none;color:var(--err);font-size:12.5px;font-weight:500;margin-top:7px;}\r\n#gwiba .gwiba-err.show{display:block;animation:gwibaShakeIn .3s ease;}\r\n@keyframes gwibaShakeIn{0%{opacity:0;transform:translateX(-4px)}100%{opacity:1;transform:none}}\r\n\r\n\/* currency prefix *\/\r\n#gwiba .gwiba-money{position:relative;}\r\n#gwiba .gwiba-money .gwiba-cur{position:absolute;left:15px;top:50%;transform:translateY(-50%);\r\n  font-size:14px;font-weight:600;color:var(--muted);pointer-events:none;}\r\n#gwiba .gwiba-money .gwiba-input{padding-left:52px;}\r\n\r\n\/* ---- Radio \/ choice rows ------------------------------------------ *\/\r\n#gwiba .gwiba-choices{display:grid;gap:10px;}\r\n#gwiba .gwiba-choices.row{grid-template-columns:1fr 1fr;}\r\n#gwiba .gwiba-choice{display:flex;align-items:center;gap:12px;cursor:pointer;\r\n  border:1.5px solid var(--line);border-radius:var(--radius-in);padding:13px 15px;\r\n  transition:border-color .18s,background .18s,box-shadow .18s;user-select:none;}\r\n#gwiba .gwiba-choice:hover{border-color:#C7D6E6;background:#FBFDFF;}\r\n#gwiba .gwiba-choice input{position:absolute;opacity:0;width:0;height:0;}\r\n#gwiba .gwiba-dot{width:20px;height:20px;border-radius:50%;border:2px solid #C4D0DE;\r\n  flex:none;position:relative;transition:border-color .18s;}\r\n#gwiba .gwiba-dot::after{content:\"\";position:absolute;inset:3px;border-radius:50%;\r\n  background:var(--grad);transform:scale(0);transition:transform .18s;}\r\n#gwiba .gwiba-box{width:20px;height:20px;border-radius:6px;border:2px solid #C4D0DE;\r\n  flex:none;position:relative;transition:border-color .18s,background .18s;}\r\n#gwiba .gwiba-box::after{content:\"\";position:absolute;left:5px;top:1.5px;width:6px;height:11px;\r\n  border:solid #fff;border-width:0 2.5px 2.5px 0;transform:rotate(45deg) scale(0);\r\n  transition:transform .18s;}\r\n#gwiba .gwiba-choice .gwiba-ctxt{font-size:14.5px;font-weight:500;}\r\n#gwiba .gwiba-choice.sel{border-color:var(--accent);background:rgba(63,166,221,.06);\r\n  box-shadow:0 0 0 3px rgba(63,166,221,.10);}\r\n#gwiba .gwiba-choice.sel .gwiba-dot{border-color:var(--accent);}\r\n#gwiba .gwiba-choice.sel .gwiba-dot::after{transform:scale(1);}\r\n#gwiba .gwiba-choice.sel .gwiba-box{border-color:var(--accent);background:var(--grad);}\r\n#gwiba .gwiba-choice.sel .gwiba-box::after{transform:rotate(45deg) scale(1);}\r\n\r\n\/* ---- Sum-insured total strip ---------------------------------------- *\/\r\n#gwiba .gwiba-total{display:flex;justify-content:space-between;align-items:center;\r\n  background:rgba(63,166,221,.08);border:1.5px solid rgba(63,166,221,.25);\r\n  border-radius:var(--radius-in);padding:14px 18px;margin-top:6px;}\r\n#gwiba .gwiba-total .lab{font-size:13.5px;font-weight:600;color:var(--ink);}\r\n#gwiba .gwiba-total .val{font-family:'Poppins',sans-serif;font-size:18px;font-weight:700;color:var(--accent);}\r\n\r\n\/* ---- Review -------------------------------------------------------- *\/\r\n#gwiba .gwiba-summary{display:grid;gap:14px;}\r\n#gwiba .gwiba-sblock{border:1px solid var(--line-2);border-radius:var(--radius-in);\r\n  padding:16px 18px;background:#FCFDFE;}\r\n#gwiba .gwiba-sblock h4{font-family:'Poppins',sans-serif;font-size:13px;font-weight:600;\r\n  color:var(--primary);letter-spacing:.02em;margin-bottom:12px;display:flex;\r\n  align-items:center;gap:8px;text-transform:uppercase;}\r\n#gwiba .gwiba-srow{display:flex;justify-content:space-between;gap:16px;font-size:14px;\r\n  padding:6px 0;border-top:1px dashed var(--line);}\r\n#gwiba .gwiba-srow:first-of-type{border-top:0;}\r\n#gwiba .gwiba-srow .k{color:var(--muted);}\r\n#gwiba .gwiba-srow .v{color:var(--ink);font-weight:600;text-align:right;}\r\n#gwiba .gwiba-tags{display:flex;flex-wrap:wrap;gap:8px;}\r\n#gwiba .gwiba-tag{font-size:12.5px;font-weight:600;color:var(--primary);\r\n  background:rgba(57,54,128,.09);border:1px solid rgba(57,54,128,.15);\r\n  padding:6px 11px;border-radius:99px;}\r\n\r\n\/* ---- Notice \/ reassurance ----------------------------------------- *\/\r\n#gwiba .gwiba-note{display:flex;gap:11px;align-items:flex-start;font-size:13px;\r\n  color:var(--muted);background:#F3F4FB;border:1px solid #E2E4F3;\r\n  border-radius:var(--radius-in);padding:13px 15px;margin-top:4px;}\r\n#gwiba .gwiba-note svg{flex:none;width:17px;height:17px;stroke:var(--primary);margin-top:1px;}\r\n\r\n\/* ---- Signature pad -------------------------------------------------- *\/\r\n#gwiba .gwiba-sigwrap{position:relative;border:1.5px solid var(--line);border-radius:var(--radius-in);\r\n  background:#fff;overflow:hidden;transition:border-color .2s,box-shadow .2s;}\r\n#gwiba .gwiba-sigwrap.focus{border-color:var(--accent);box-shadow:0 0 0 4px rgba(63,166,221,.14);}\r\n#gwiba .gwiba-sigcanvas{display:block;width:100%;height:170px;touch-action:none;cursor:crosshair;}\r\n#gwiba .gwiba-sig-placeholder{position:absolute;left:16px;bottom:12px;color:#B7C1D1;\r\n  font-size:13px;pointer-events:none;transition:opacity .15s;}\r\n#gwiba .gwiba-sig-placeholder.hide{opacity:0;}\r\n#gwiba .gwiba-sig-actions{display:flex;justify-content:flex-end;margin-top:8px;}\r\n#gwiba .gwiba-sig-actions .gwiba-btn{padding:8px 16px;font-size:13px;}\r\n\r\n\/* ---- Footer \/ buttons --------------------------------------------- *\/\r\n#gwiba .gwiba-foot{display:flex;justify-content:space-between;align-items:center;gap:14px;\r\n  margin-top:30px;}\r\n#gwiba .gwiba-btn{position:relative;font-size:15px;font-weight:600;border-radius:var(--radius-in);\r\n  padding:14px 26px;border:none;cursor:pointer;display:inline-flex;align-items:center;\r\n  justify-content:center;gap:9px;transition:transform .16s,box-shadow .2s,background .2s;\r\n  overflow:hidden;}\r\n#gwiba .gwiba-btn:active{transform:translateY(1px);}\r\n#gwiba .gwiba-btn:focus-visible{outline:3px solid rgba(63,166,221,.4);outline-offset:2px;}\r\n#gwiba .gwiba-primary{background:var(--grad);color:#fff;box-shadow:var(--shadow-btn);}\r\n#gwiba .gwiba-primary:hover{transform:translateY(-2px);box-shadow:0 12px 26px rgba(57,54,128,.36);}\r\n#gwiba .gwiba-ghost{background:#fff;color:var(--muted);border:1.5px solid var(--line);}\r\n#gwiba .gwiba-ghost:hover{border-color:#C7D6E6;color:var(--ink);background:#FBFDFF;}\r\n#gwiba .gwiba-btn.wide{width:100%;}\r\n#gwiba .gwiba-btn .gwiba-spin{width:18px;height:18px;border:2.5px solid rgba(255,255,255,.45);\r\n  border-top-color:#fff;border-radius:50%;display:none;animation:gwibaSpin .7s linear infinite;}\r\n#gwiba .gwiba-ghost .gwiba-spin{border-color:rgba(101,117,139,.4);border-top-color:var(--muted);}\r\n#gwiba .gwiba-btn.loading .gwiba-spin{display:block;}\r\n#gwiba .gwiba-btn.loading .gwiba-btxt{opacity:.7;}\r\n#gwiba .gwiba-btn[disabled]{opacity:.6;cursor:not-allowed;}\r\n@keyframes gwibaSpin{to{transform:rotate(360deg)}}\r\n\r\n\/* ---- Exit control + leave confirmation ----------------------------- *\/\r\n#gwiba .gwiba-exit{position:absolute;top:14px;right:14px;width:34px;height:34px;border-radius:50%;\r\n  border:1.5px solid var(--line);background:#fff;color:var(--muted);display:flex;align-items:center;\r\n  justify-content:center;cursor:pointer;transition:border-color .18s,color .18s,background .18s,transform .3s;z-index:6;}\r\n#gwiba .gwiba-exit:hover{border-color:#C7D6E6;color:var(--ink);background:#FBFDFF;transform:rotate(90deg);}\r\n#gwiba .gwiba-exit:focus-visible{outline:3px solid rgba(63,166,221,.4);outline-offset:2px;}\r\n#gwiba .gwiba-exit svg{width:15px;height:15px;stroke:currentColor;stroke-width:2.2;fill:none;stroke-linecap:round;stroke-linejoin:round;}\r\n#gwiba .gwiba-confirm{position:absolute;inset:0;background:rgba(248,249,251,.88);backdrop-filter:blur(3px);\r\n  -webkit-backdrop-filter:blur(3px);display:flex;align-items:center;justify-content:center;\r\n  z-index:12;padding:24px;animation:gwibaFade .2s ease;}\r\n#gwiba .gwiba-confirm[hidden]{display:none;}\r\n@keyframes gwibaFade{from{opacity:0}to{opacity:1}}\r\n#gwiba .gwiba-confirm-box{background:#fff;border:1px solid var(--line-2);border-radius:16px;\r\n  box-shadow:var(--shadow-m);padding:28px 26px;max-width:360px;width:100%;text-align:center;\r\n  animation:gwibaIn .28s cubic-bezier(.22,.61,.36,1);}\r\n#gwiba .gwiba-confirm-ic{width:52px;height:52px;border-radius:50%;background:rgba(63,166,221,.10);\r\n  display:flex;align-items:center;justify-content:center;margin:0 auto 14px;}\r\n#gwiba .gwiba-confirm-ic svg{width:24px;height:24px;stroke:var(--primary);fill:none;stroke-width:2;stroke-linecap:round;stroke-linejoin:round;}\r\n#gwiba .gwiba-confirm-box h3{font-family:'Poppins',sans-serif;font-size:18px;font-weight:600;color:var(--ink);margin-bottom:6px;}\r\n#gwiba .gwiba-confirm-box p{color:var(--muted);font-size:14px;margin-bottom:20px;}\r\n#gwiba .gwiba-confirm-actions{display:flex;gap:10px;}\r\n#gwiba .gwiba-confirm-actions .gwiba-btn{flex:1;padding:12px 16px;}\r\n\r\n\/* ---- Welcome (photo + content split hero) --------------------------- *\/\r\n#gwiba .gwiba-card.gwiba-card--hero::before{display:none;}\r\n#gwiba .gwiba-hero{display:flex;align-items:stretch;gap:32px;min-height:360px;}\r\n#gwiba .gwiba-hero-media{flex:1 1 44%;border-radius:28px;overflow:hidden;background:#DCE3EC;\r\n  box-shadow:0 20px 45px rgba(57,54,128,.16);position:relative;}\r\n#gwiba .gwiba-hero-media img{width:100%;height:100%;min-height:360px;object-fit:cover;display:block;}\r\n#gwiba .gwiba-hero-content{flex:1 1 56%;display:flex;flex-direction:column;justify-content:center;\r\n  padding:16px 12px 16px 4px;}\r\n#gwiba .gwiba-hero-content h1{font-family:'Poppins',sans-serif;font-weight:700;\r\n  font-size:clamp(24px,3.4vw,34px);line-height:1.2;letter-spacing:-.02em;\r\n  color:var(--ink);margin-bottom:16px;}\r\n#gwiba .gwiba-hero-content h1 .hl{color:var(--primary);}\r\n#gwiba .gwiba-hero-content p{color:var(--muted);font-size:15.5px;line-height:1.65;\r\n  max-width:42ch;margin-bottom:26px;}\r\n#gwiba .gwiba-hero-content .gwiba-btn{align-self:flex-start;padding:13px 24px;font-size:14.5px;}\r\n@media(max-width:680px){\r\n  #gwiba .gwiba-hero{flex-direction:column;min-height:0;}\r\n  #gwiba .gwiba-hero-media{flex:none;width:100%;aspect-ratio:16\/11;}\r\n  #gwiba .gwiba-hero-media img{min-height:0;}\r\n  #gwiba .gwiba-hero-content{padding:22px 4px 4px;}\r\n}\r\n\r\n\/* ---- Success ------------------------------------------------------- *\/\r\n#gwiba .gwiba-success{text-align:center;padding:18px 6px;}\r\n#gwiba .gwiba-scheck{width:104px;height:104px;margin:6px auto 26px;position:relative;}\r\n#gwiba .gwiba-scheck .disc{position:absolute;inset:0;border-radius:50%;background:var(--grad);\r\n  box-shadow:0 18px 40px rgba(57,54,128,.34);animation:gwibaPop .55s cubic-bezier(.2,.8,.3,1.4);}\r\n#gwiba .gwiba-scheck svg{position:absolute;inset:0;margin:auto;width:52px;height:52px;\r\n  stroke:#fff;fill:none;stroke-width:4;stroke-linecap:round;stroke-linejoin:round;}\r\n#gwiba .gwiba-scheck svg path{stroke-dasharray:48;stroke-dashoffset:48;\r\n  animation:gwibaDraw .5s .35s forwards cubic-bezier(.65,0,.35,1);}\r\n@keyframes gwibaPop{0%{transform:scale(0)}70%{transform:scale(1.06)}100%{transform:scale(1)}}\r\n@keyframes gwibaDraw{to{stroke-dashoffset:0}}\r\n#gwiba .gwiba-success h1{font-family:'Poppins',sans-serif;font-weight:700;font-size:29px;\r\n  margin-bottom:14px;color:var(--ink);}\r\n#gwiba .gwiba-success p{color:var(--muted);font-size:15.5px;max-width:44ch;margin:0 auto 12px;}\r\n#gwiba .gwiba-success .gwiba-btn{margin-top:22px;padding:15px 32px;}\r\n\r\n\/* ---- Responsive ---------------------------------------------------- *\/\r\n@media(max-width:560px){\r\n  #gwiba{padding:16px 10px 36px;}\r\n  #gwiba .gwiba-card{padding:26px 20px;border-radius:14px;}\r\n  #gwiba .gwiba-grid-2,#gwiba .gwiba-grid-3{grid-template-columns:1fr;}\r\n  #gwiba .gwiba-choices.row{grid-template-columns:1fr;}\r\n  #gwiba h2.gwiba-h{font-size:22px;}\r\n  #gwiba .gwiba-foot .gwiba-btn{padding:13px 18px;font-size:14.5px;}\r\n}\r\n@media(prefers-reduced-motion:reduce){\r\n  #gwiba *{animation:none!important;transition:none!important;}\r\n}\r\n<\/style>\r\n\r\n<div class=\"gwiba-shell\">\r\n  <div class=\"gwiba-progress\" id=\"gwibaProgress\">\r\n    <div class=\"gwiba-progress-top\">\r\n      <span class=\"gwiba-step-label\">Step <b id=\"gwibaStepNo\">1<\/b> of 8<\/span>\r\n      <span class=\"gwiba-step-name\" id=\"gwibaStepName\">Welcome<\/span>\r\n    <\/div>\r\n    <div class=\"gwiba-track\"><div class=\"gwiba-fill\" id=\"gwibaFill\"><\/div><\/div>\r\n  <\/div>\r\n\r\n  <div class=\"gwiba-card\">\r\n\r\n    <section class=\"gwiba-step active\" data-step=\"1\">\r\n      <div class=\"gwiba-hero\">\r\n        <div class=\"gwiba-hero-media\">\r\n          <!-- REPLACE: swap for your own photography, uploaded to the WP media library -->\r\n          <img decoding=\"async\" src=\"https:\/\/geminia.co.ke\/dev\/wp-content\/uploads\/2026\/08\/WIBA.jpg\" alt=\"Workers on a factory floor\" loading=\"lazy\">\r\n        <\/div>\r\n        <div class=\"gwiba-hero-content\">\r\n          <h1>Protect Your Employees <span class=\"hl\">in Minutes<\/span><\/h1>\r\n          <p>Answer a few questions about your business and employees, and we'll prepare your WIBA Insurance proposal for a Geminia advisor to quote.<\/p>\r\n          <button class=\"gwiba-btn gwiba-primary\" data-cta=\"start\">\r\n            <span class=\"gwiba-spin\"><\/span><span class=\"gwiba-btxt\">Get Started \u2192<\/span>\r\n          <\/button>\r\n        <\/div>\r\n      <\/div>\r\n    <\/section>\r\n\r\n    <section class=\"gwiba-step\" data-step=\"2\">\r\n      <span class=\"gwiba-eyebrow\">About you<\/span>\r\n      <h2 class=\"gwiba-h\">Proposer's details<\/h2>\r\n      <p class=\"gwiba-sub\">Part 1 of the official Geminia WIBA Insurance proposal form \u2014 indemnity to the employer under the Work Injury Benefits Act, 2007.<\/p>\r\n\r\n      <div class=\"gwiba-field\">\r\n        <label class=\"gwiba-lab\" for=\"fullName\">Name in full <span class=\"gwiba-req\">*<\/span><\/label>\r\n        <input class=\"gwiba-input\" id=\"fullName\" type=\"text\" placeholder=\"e.g. Company name\" autocomplete=\"organization\">\r\n        <div class=\"gwiba-err\" data-err=\"fullName\">Please enter the proposer's name.<\/div>\r\n      <\/div>\r\n\r\n      <div class=\"gwiba-grid-2\">\r\n        <div class=\"gwiba-field\">\r\n          <label class=\"gwiba-lab\" for=\"kraPin\">KRA PIN number <span style=\"font-weight:400;color:var(--muted);\">(optional)<\/span><\/label>\r\n          <input class=\"gwiba-input\" id=\"kraPin\" type=\"text\" placeholder=\"e.g. A001234567X\">\r\n        <\/div>\r\n        <div class=\"gwiba-field\">\r\n          <label class=\"gwiba-lab\" for=\"email\">Email address <span class=\"gwiba-req\">*<\/span><\/label>\r\n          <input class=\"gwiba-input\" id=\"email\" type=\"email\" placeholder=\"you@example.com\" autocomplete=\"email\" inputmode=\"email\">\r\n          <div class=\"gwiba-err\" data-err=\"email\">Enter a valid email address.<\/div>\r\n        <\/div>\r\n      <\/div>\r\n\r\n      <div class=\"gwiba-grid-3\">\r\n        <div class=\"gwiba-field\">\r\n          <label class=\"gwiba-lab\" for=\"postalAddress\">Postal address <span style=\"font-weight:400;color:var(--muted);\">(optional)<\/span><\/label>\r\n          <input class=\"gwiba-input\" id=\"postalAddress\" type=\"text\" placeholder=\"e.g. P.O. Box 1234\">\r\n        <\/div>\r\n        <div class=\"gwiba-field\">\r\n          <label class=\"gwiba-lab\" for=\"postalCode\">Postal code <span style=\"font-weight:400;color:var(--muted);\">(optional)<\/span><\/label>\r\n          <input class=\"gwiba-input\" id=\"postalCode\" type=\"text\" placeholder=\"e.g. 00100\">\r\n        <\/div>\r\n        <div class=\"gwiba-field\">\r\n          <label class=\"gwiba-lab\" for=\"town\">Town <span style=\"font-weight:400;color:var(--muted);\">(optional)<\/span><\/label>\r\n          <input class=\"gwiba-input\" id=\"town\" type=\"text\" placeholder=\"e.g. Nairobi\">\r\n        <\/div>\r\n      <\/div>\r\n\r\n      <div class=\"gwiba-grid-2\">\r\n        <div class=\"gwiba-field\">\r\n          <label class=\"gwiba-lab\" for=\"telephone\">Telephone number(s) <span style=\"font-weight:400;color:var(--muted);\">(optional)<\/span><\/label>\r\n          <input class=\"gwiba-input\" id=\"telephone\" type=\"text\">\r\n        <\/div>\r\n        <div class=\"gwiba-field\">\r\n          <label class=\"gwiba-lab\" for=\"faxNo\">Fax number <span style=\"font-weight:400;color:var(--muted);\">(optional)<\/span><\/label>\r\n          <input class=\"gwiba-input\" id=\"faxNo\" type=\"text\">\r\n        <\/div>\r\n      <\/div>\r\n\r\n      <div class=\"gwiba-field\">\r\n        <label class=\"gwiba-lab\" for=\"location\">Physical address \/ location of premises <span class=\"gwiba-req\">*<\/span><\/label>\r\n        <input class=\"gwiba-input\" id=\"location\" type=\"text\" placeholder=\"e.g. Industrial Area, Nairobi\">\r\n        <div class=\"gwiba-err\" data-err=\"location\">Please enter the location of the premises.<\/div>\r\n      <\/div>\r\n\r\n      <div class=\"gwiba-field\">\r\n        <label class=\"gwiba-lab\" for=\"natureOfBusiness\">Nature of business \/ occupation <span style=\"font-weight:400;color:var(--muted);\">(optional)<\/span><\/label>\r\n        <input class=\"gwiba-input\" id=\"natureOfBusiness\" type=\"text\" placeholder=\"e.g. Manufacturing\">\r\n      <\/div>\r\n\r\n      <div class=\"gwiba-grid-2\">\r\n        <div class=\"gwiba-field\">\r\n          <label class=\"gwiba-lab\" for=\"periodFrom\">Period of insurance \u2014 From <span style=\"font-weight:400;color:var(--muted);\">(optional)<\/span><\/label>\r\n          <input class=\"gwiba-input\" id=\"periodFrom\" type=\"date\">\r\n        <\/div>\r\n        <div class=\"gwiba-field\">\r\n          <label class=\"gwiba-lab\" for=\"periodTo\">Period of insurance \u2014 To <span style=\"font-weight:400;color:var(--muted);\">(optional)<\/span><\/label>\r\n          <input class=\"gwiba-input\" id=\"periodTo\" type=\"date\">\r\n        <\/div>\r\n      <\/div>\r\n\r\n      <div class=\"gwiba-note\">\r\n        <svg viewBox=\"0 0 24 24\" fill=\"none\" stroke-width=\"2\" stroke-linecap=\"round\" stroke-linejoin=\"round\"><rect x=\"3\" y=\"11\" width=\"18\" height=\"11\" rx=\"2\"\/><path d=\"M7 11V7a5 5 0 0 1 10 0v4\"\/><\/svg>\r\n        <span>Please have your Certificate of Incorporation and KRA PIN Certificate ready \u2014 your advisor will request copies.<\/span>\r\n      <\/div>\r\n    <\/section>\r\n\r\n    <section class=\"gwiba-step\" data-step=\"3\">\r\n      <span class=\"gwiba-eyebrow\">Premises &amp; machinery<\/span>\r\n      <h2 class=\"gwiba-h\">A few questions about your premises<\/h2>\r\n      <p class=\"gwiba-sub\">The truth of these statements is a condition precedent to liability \u2014 please answer in full.<\/p>\r\n\r\n      <div class=\"gwiba-field\">\r\n        <label class=\"gwiba-lab\">Does any law or regulation governing the conduct or maintenance of premises apply to your premises? <span class=\"gwiba-req\">*<\/span><\/label>\r\n        <div class=\"gwiba-choices row\" data-radio=\"lawsApply\">\r\n          <label class=\"gwiba-choice\"><input type=\"radio\" name=\"lawsApply\" value=\"No\"><span class=\"gwiba-dot\"><\/span><span class=\"gwiba-ctxt\">No<\/span><\/label>\r\n          <label class=\"gwiba-choice\"><input type=\"radio\" name=\"lawsApply\" value=\"Yes\"><span class=\"gwiba-dot\"><\/span><span class=\"gwiba-ctxt\">Yes<\/span><\/label>\r\n        <\/div>\r\n        <div class=\"gwiba-err\" data-err=\"lawsApply\">Please let us know.<\/div>\r\n      <\/div>\r\n      <div class=\"gwiba-field\" id=\"gwibaLawsDetailWrap\" style=\"display:none;\">\r\n        <label class=\"gwiba-lab\" for=\"lawsDetail\">If so, name such laws and regulations<\/label>\r\n        <input class=\"gwiba-input\" id=\"lawsDetail\" type=\"text\">\r\n      <\/div>\r\n\r\n      <div class=\"gwiba-field\">\r\n        <label class=\"gwiba-lab\">Do you have any circular saws or other machinery driven by steam, gas, water, electricity or other mechanical power? <span class=\"gwiba-req\">*<\/span><\/label>\r\n        <div class=\"gwiba-choices row\" data-radio=\"circularSaws\">\r\n          <label class=\"gwiba-choice\"><input type=\"radio\" name=\"circularSaws\" value=\"No\"><span class=\"gwiba-dot\"><\/span><span class=\"gwiba-ctxt\">No<\/span><\/label>\r\n          <label class=\"gwiba-choice\"><input type=\"radio\" name=\"circularSaws\" value=\"Yes\"><span class=\"gwiba-dot\"><\/span><span class=\"gwiba-ctxt\">Yes<\/span><\/label>\r\n        <\/div>\r\n        <div class=\"gwiba-err\" data-err=\"circularSaws\">Please let us know.<\/div>\r\n      <\/div>\r\n      <div class=\"gwiba-field\" id=\"gwibaSawsDetailWrap\" style=\"display:none;\">\r\n        <label class=\"gwiba-lab\" for=\"sawsDetail\">If yes, give details<\/label>\r\n        <input class=\"gwiba-input\" id=\"sawsDetail\" type=\"text\">\r\n      <\/div>\r\n\r\n      <div class=\"gwiba-field\">\r\n        <label class=\"gwiba-lab\">Do you have any boilers? <span class=\"gwiba-req\">*<\/span><\/label>\r\n        <div class=\"gwiba-choices row\" data-radio=\"boilers\">\r\n          <label class=\"gwiba-choice\"><input type=\"radio\" name=\"boilers\" value=\"No\"><span class=\"gwiba-dot\"><\/span><span class=\"gwiba-ctxt\">No<\/span><\/label>\r\n          <label class=\"gwiba-choice\"><input type=\"radio\" name=\"boilers\" value=\"Yes\"><span class=\"gwiba-dot\"><\/span><span class=\"gwiba-ctxt\">Yes<\/span><\/label>\r\n        <\/div>\r\n        <div class=\"gwiba-err\" data-err=\"boilers\">Please let us know.<\/div>\r\n      <\/div>\r\n      <div class=\"gwiba-field\" id=\"gwibaBoilersDetailWrap\" style=\"display:none;\">\r\n        <label class=\"gwiba-lab\" for=\"boilersDetail\">If yes, give details<\/label>\r\n        <input class=\"gwiba-input\" id=\"boilersDetail\" type=\"text\">\r\n      <\/div>\r\n\r\n      <div class=\"gwiba-field\">\r\n        <label class=\"gwiba-lab\">Do you use acids, gases, chemicals or explosives? <span class=\"gwiba-req\">*<\/span><\/label>\r\n        <div class=\"gwiba-choices row\" data-radio=\"acidsChemicals\">\r\n          <label class=\"gwiba-choice\"><input type=\"radio\" name=\"acidsChemicals\" value=\"No\"><span class=\"gwiba-dot\"><\/span><span class=\"gwiba-ctxt\">No<\/span><\/label>\r\n          <label class=\"gwiba-choice\"><input type=\"radio\" name=\"acidsChemicals\" value=\"Yes\"><span class=\"gwiba-dot\"><\/span><span class=\"gwiba-ctxt\">Yes<\/span><\/label>\r\n        <\/div>\r\n        <div class=\"gwiba-err\" data-err=\"acidsChemicals\">Please let us know.<\/div>\r\n      <\/div>\r\n      <div class=\"gwiba-field\" id=\"gwibaAcidsDetailWrap\" style=\"display:none;\">\r\n        <label class=\"gwiba-lab\" for=\"acidsDetail\">If yes, give details<\/label>\r\n        <input class=\"gwiba-input\" id=\"acidsDetail\" type=\"text\">\r\n      <\/div>\r\n\r\n      <div class=\"gwiba-field\">\r\n        <label class=\"gwiba-lab\">Do you handle or use radioisotopes, radioactive substances, or other sources of ionising radiation? <span class=\"gwiba-req\">*<\/span><\/label>\r\n        <div class=\"gwiba-choices row\" data-radio=\"radioactive\">\r\n          <label class=\"gwiba-choice\"><input type=\"radio\" name=\"radioactive\" value=\"No\"><span class=\"gwiba-dot\"><\/span><span class=\"gwiba-ctxt\">No<\/span><\/label>\r\n          <label class=\"gwiba-choice\"><input type=\"radio\" name=\"radioactive\" value=\"Yes\"><span class=\"gwiba-dot\"><\/span><span class=\"gwiba-ctxt\">Yes<\/span><\/label>\r\n        <\/div>\r\n        <div class=\"gwiba-err\" data-err=\"radioactive\">Please let us know.<\/div>\r\n      <\/div>\r\n      <div class=\"gwiba-field\" id=\"gwibaRadioactiveDetailWrap\" style=\"display:none;\">\r\n        <label class=\"gwiba-lab\" for=\"radioactiveDetail\">If yes, give details<\/label>\r\n        <input class=\"gwiba-input\" id=\"radioactiveDetail\" type=\"text\">\r\n      <\/div>\r\n    <\/section>\r\n\r\n    <section class=\"gwiba-step\" data-step=\"4\">\r\n      <span class=\"gwiba-eyebrow\">Quick check<\/span>\r\n      <h2 class=\"gwiba-h\">Prior insurance &amp; employee health<\/h2>\r\n      <p class=\"gwiba-sub\">A few background questions.<\/p>\r\n\r\n      <div class=\"gwiba-field\">\r\n        <label class=\"gwiba-lab\">Are you at present insured, or have you ever proposed for, a workmen's compensation policy or work injury benefits policy? <span class=\"gwiba-req\">*<\/span><\/label>\r\n        <div class=\"gwiba-choices row\" data-radio=\"workmenCompProposed\">\r\n          <label class=\"gwiba-choice\"><input type=\"radio\" name=\"workmenCompProposed\" value=\"No\"><span class=\"gwiba-dot\"><\/span><span class=\"gwiba-ctxt\">No<\/span><\/label>\r\n          <label class=\"gwiba-choice\"><input type=\"radio\" name=\"workmenCompProposed\" value=\"Yes\"><span class=\"gwiba-dot\"><\/span><span class=\"gwiba-ctxt\">Yes<\/span><\/label>\r\n        <\/div>\r\n        <div class=\"gwiba-err\" data-err=\"workmenCompProposed\">Please let us know.<\/div>\r\n      <\/div>\r\n\r\n      <div class=\"gwiba-field\">\r\n        <label class=\"gwiba-lab\">Have such proposals or renewals ever been declined or withdrawn? <span class=\"gwiba-req\">*<\/span><\/label>\r\n        <div class=\"gwiba-choices row\" data-radio=\"proposalsDeclined\">\r\n          <label class=\"gwiba-choice\"><input type=\"radio\" name=\"proposalsDeclined\" value=\"No\"><span class=\"gwiba-dot\"><\/span><span class=\"gwiba-ctxt\">No<\/span><\/label>\r\n          <label class=\"gwiba-choice\"><input type=\"radio\" name=\"proposalsDeclined\" value=\"Yes\"><span class=\"gwiba-dot\"><\/span><span class=\"gwiba-ctxt\">Yes<\/span><\/label>\r\n        <\/div>\r\n        <div class=\"gwiba-err\" data-err=\"proposalsDeclined\">Please let us know.<\/div>\r\n      <\/div>\r\n      <div class=\"gwiba-field\" id=\"gwibaDeclinedDetailWrap\" style=\"display:none;\">\r\n        <label class=\"gwiba-lab\" for=\"declinedDetail\">If yes, give details<\/label>\r\n        <input class=\"gwiba-input\" id=\"declinedDetail\" type=\"text\">\r\n      <\/div>\r\n\r\n      <div class=\"gwiba-field\">\r\n        <label class=\"gwiba-lab\">Have increased rates been required for such proposals or renewals? <span class=\"gwiba-req\">*<\/span><\/label>\r\n        <div class=\"gwiba-choices row\" data-radio=\"increasedRatesRequired\">\r\n          <label class=\"gwiba-choice\"><input type=\"radio\" name=\"increasedRatesRequired\" value=\"No\"><span class=\"gwiba-dot\"><\/span><span class=\"gwiba-ctxt\">No<\/span><\/label>\r\n          <label class=\"gwiba-choice\"><input type=\"radio\" name=\"increasedRatesRequired\" value=\"Yes\"><span class=\"gwiba-dot\"><\/span><span class=\"gwiba-ctxt\">Yes<\/span><\/label>\r\n        <\/div>\r\n        <div class=\"gwiba-err\" data-err=\"increasedRatesRequired\">Please let us know.<\/div>\r\n      <\/div>\r\n\r\n      <div class=\"gwiba-field\">\r\n        <label class=\"gwiba-lab\">Do you have any employee with a pre-existing medical condition? <span class=\"gwiba-req\">*<\/span><\/label>\r\n        <div class=\"gwiba-choices row\" data-radio=\"preExistingConditions\">\r\n          <label class=\"gwiba-choice\"><input type=\"radio\" name=\"preExistingConditions\" value=\"No\"><span class=\"gwiba-dot\"><\/span><span class=\"gwiba-ctxt\">No<\/span><\/label>\r\n          <label class=\"gwiba-choice\"><input type=\"radio\" name=\"preExistingConditions\" value=\"Yes\"><span class=\"gwiba-dot\"><\/span><span class=\"gwiba-ctxt\">Yes<\/span><\/label>\r\n        <\/div>\r\n        <div class=\"gwiba-err\" data-err=\"preExistingConditions\">Please let us know.<\/div>\r\n      <\/div>\r\n      <div class=\"gwiba-field\" id=\"gwibaPreExistingDetailWrap\" style=\"display:none;\">\r\n        <label class=\"gwiba-lab\" for=\"preExistingDetail\">If yes, please give details<\/label>\r\n        <input class=\"gwiba-input\" id=\"preExistingDetail\" type=\"text\">\r\n      <\/div>\r\n    <\/section>\r\n\r\n    <section class=\"gwiba-step\" data-step=\"5\">\r\n      <span class=\"gwiba-eyebrow\">Your employees<\/span>\r\n      <h2 class=\"gwiba-h\">Employee schedule<\/h2>\r\n      <p class=\"gwiba-sub\">Employees being workers as defined by Section 5 of the Work Injury Benefits Act, 2007. Maximum age allowed in the policy is 65 years.<\/p>\r\n\r\n      <div class=\"gwiba-sec\">Employee group 1<\/div>\r\n      <div class=\"gwiba-field\">\r\n        <label class=\"gwiba-lab\" for=\"emp1Names\">Names \/ number of employees <span class=\"gwiba-req\">*<\/span><\/label>\r\n        <input class=\"gwiba-input\" id=\"emp1Names\" type=\"text\" placeholder=\"e.g. 12 factory workers\">\r\n        <div class=\"gwiba-err\" data-err=\"emp1Names\">Please describe this employee group.<\/div>\r\n      <\/div>\r\n      <div class=\"gwiba-grid-2\">\r\n        <div class=\"gwiba-field\">\r\n          <label class=\"gwiba-lab\" for=\"emp1Occupation\">Description of occupation<\/label>\r\n          <input class=\"gwiba-input\" id=\"emp1Occupation\" type=\"text\" placeholder=\"e.g. Machine operators\">\r\n        <\/div>\r\n        <div class=\"gwiba-field\">\r\n          <label class=\"gwiba-lab\" for=\"emp1Salary\">Estimated annual salary\/wages<\/label>\r\n          <div class=\"gwiba-money\"><span class=\"gwiba-cur\">KES<\/span><input class=\"gwiba-input\" id=\"emp1Salary\" type=\"text\" inputmode=\"numeric\" placeholder=\"0\"><\/div>\r\n        <\/div>\r\n      <\/div>\r\n\r\n      <div class=\"gwiba-sec\">Employee group 2 <span style=\"font-weight:400;color:var(--muted);text-transform:none;letter-spacing:0;\">(optional)<\/span><\/div>\r\n      <div class=\"gwiba-field\"><label class=\"gwiba-lab\" for=\"emp2Names\">Names \/ number of employees<\/label><input class=\"gwiba-input\" id=\"emp2Names\" type=\"text\"><\/div>\r\n      <div class=\"gwiba-grid-2\">\r\n        <div class=\"gwiba-field\"><label class=\"gwiba-lab\" for=\"emp2Occupation\">Description of occupation<\/label><input class=\"gwiba-input\" id=\"emp2Occupation\" type=\"text\"><\/div>\r\n        <div class=\"gwiba-field\"><label class=\"gwiba-lab\" for=\"emp2Salary\">Estimated annual salary\/wages<\/label>\r\n          <div class=\"gwiba-money\"><span class=\"gwiba-cur\">KES<\/span><input class=\"gwiba-input\" id=\"emp2Salary\" type=\"text\" inputmode=\"numeric\" placeholder=\"0\"><\/div><\/div>\r\n      <\/div>\r\n\r\n      <div class=\"gwiba-sec\">Employee group 3 <span style=\"font-weight:400;color:var(--muted);text-transform:none;letter-spacing:0;\">(optional)<\/span><\/div>\r\n      <div class=\"gwiba-field\"><label class=\"gwiba-lab\" for=\"emp3Names\">Names \/ number of employees<\/label><input class=\"gwiba-input\" id=\"emp3Names\" type=\"text\"><\/div>\r\n      <div class=\"gwiba-grid-2\">\r\n        <div class=\"gwiba-field\"><label class=\"gwiba-lab\" for=\"emp3Occupation\">Description of occupation<\/label><input class=\"gwiba-input\" id=\"emp3Occupation\" type=\"text\"><\/div>\r\n        <div class=\"gwiba-field\"><label class=\"gwiba-lab\" for=\"emp3Salary\">Estimated annual salary\/wages<\/label>\r\n          <div class=\"gwiba-money\"><span class=\"gwiba-cur\">KES<\/span><input class=\"gwiba-input\" id=\"emp3Salary\" type=\"text\" inputmode=\"numeric\" placeholder=\"0\"><\/div><\/div>\r\n      <\/div>\r\n      <div class=\"gwiba-hint\">More occupation groups? List the rest with your advisor on a supplementary sheet.<\/div>\r\n\r\n      <div class=\"gwiba-field\" style=\"margin-top:24px;\">\r\n        <label class=\"gwiba-lab\">Do the above salaries include constant allowances (e.g. housing, commuters)? <span class=\"gwiba-req\">*<\/span><\/label>\r\n        <div class=\"gwiba-choices row\" data-radio=\"constantAllowanceIncluded\">\r\n          <label class=\"gwiba-choice\"><input type=\"radio\" name=\"constantAllowanceIncluded\" value=\"Yes\"><span class=\"gwiba-dot\"><\/span><span class=\"gwiba-ctxt\">Yes<\/span><\/label>\r\n          <label class=\"gwiba-choice\"><input type=\"radio\" name=\"constantAllowanceIncluded\" value=\"No\"><span class=\"gwiba-dot\"><\/span><span class=\"gwiba-ctxt\">No<\/span><\/label>\r\n        <\/div>\r\n        <div class=\"gwiba-err\" data-err=\"constantAllowanceIncluded\">Please let us know.<\/div>\r\n      <\/div>\r\n\r\n      <div class=\"gwiba-note\">\r\n        <svg viewBox=\"0 0 24 24\" fill=\"none\" stroke-width=\"2\" stroke-linecap=\"round\" stroke-linejoin=\"round\"><rect x=\"3\" y=\"11\" width=\"18\" height=\"11\" rx=\"2\"\/><path d=\"M7 11V7a5 5 0 0 1 10 0v4\"\/><\/svg>\r\n        <span>It's a condition of this policy that estimated annual wages, salaries and earnings are certified annually by your auditors within 3 months of the expiry date of the period of insurance.<\/span>\r\n      <\/div>\r\n    <\/section>\r\n\r\n    <section class=\"gwiba-step\" data-step=\"6\">\r\n      <span class=\"gwiba-eyebrow\">History<\/span>\r\n      <h2 class=\"gwiba-h\">Claims history<\/h2>\r\n      <p class=\"gwiba-sub\">Your accident\/claims record for recent years. Leave blank if not applicable.<\/p>\r\n\r\n      <div class=\"gwiba-sec\">Year 1 <span style=\"font-weight:400;color:var(--muted);text-transform:none;letter-spacing:0;\">(most recent, optional)<\/span><\/div>\r\n      <div class=\"gwiba-grid-2\">\r\n        <div class=\"gwiba-field\"><label class=\"gwiba-lab\" for=\"claim1Year\">Year<\/label><input class=\"gwiba-input\" id=\"claim1Year\" type=\"text\" inputmode=\"numeric\" placeholder=\"e.g. 2025\"><\/div>\r\n        <div class=\"gwiba-field\"><label class=\"gwiba-lab\" for=\"claim1Wages\">Wages, salaries and other earnings<\/label>\r\n          <div class=\"gwiba-money\"><span class=\"gwiba-cur\">KES<\/span><input class=\"gwiba-input\" id=\"claim1Wages\" type=\"text\" inputmode=\"numeric\" placeholder=\"0\"><\/div><\/div>\r\n      <\/div>\r\n      <div class=\"gwiba-grid-2\">\r\n        <div class=\"gwiba-field\"><label class=\"gwiba-lab\" for=\"claim1Accidents\">Number of accidents (whether or not involving claims)<\/label><input class=\"gwiba-input\" id=\"claim1Accidents\" type=\"text\" inputmode=\"numeric\"><\/div>\r\n        <div class=\"gwiba-field\"><label class=\"gwiba-lab\" for=\"claim1SettledCount\">Claims settled \u2014 number<\/label><input class=\"gwiba-input\" id=\"claim1SettledCount\" type=\"text\" inputmode=\"numeric\"><\/div>\r\n      <\/div>\r\n      <div class=\"gwiba-grid-2\">\r\n        <div class=\"gwiba-field\"><label class=\"gwiba-lab\" for=\"claim1SettledCost\">Claims settled \u2014 cost<\/label>\r\n          <div class=\"gwiba-money\"><span class=\"gwiba-cur\">KES<\/span><input class=\"gwiba-input\" id=\"claim1SettledCost\" type=\"text\" inputmode=\"numeric\" placeholder=\"0\"><\/div><\/div>\r\n        <div class=\"gwiba-field\"><label class=\"gwiba-lab\" for=\"claim1OutstandingCount\">Claims outstanding \u2014 number<\/label><input class=\"gwiba-input\" id=\"claim1OutstandingCount\" type=\"text\" inputmode=\"numeric\"><\/div>\r\n      <\/div>\r\n      <div class=\"gwiba-field\"><label class=\"gwiba-lab\" for=\"claim1OutstandingCost\">Claims outstanding \u2014 cost<\/label>\r\n        <div class=\"gwiba-money\"><span class=\"gwiba-cur\">KES<\/span><input class=\"gwiba-input\" id=\"claim1OutstandingCost\" type=\"text\" inputmode=\"numeric\" placeholder=\"0\"><\/div><\/div>\r\n\r\n      <div class=\"gwiba-sec\">Year 2 <span style=\"font-weight:400;color:var(--muted);text-transform:none;letter-spacing:0;\">(optional)<\/span><\/div>\r\n      <div class=\"gwiba-grid-2\">\r\n        <div class=\"gwiba-field\"><label class=\"gwiba-lab\" for=\"claim2Year\">Year<\/label><input class=\"gwiba-input\" id=\"claim2Year\" type=\"text\" inputmode=\"numeric\"><\/div>\r\n        <div class=\"gwiba-field\"><label class=\"gwiba-lab\" for=\"claim2Wages\">Wages, salaries and other earnings<\/label>\r\n          <div class=\"gwiba-money\"><span class=\"gwiba-cur\">KES<\/span><input class=\"gwiba-input\" id=\"claim2Wages\" type=\"text\" inputmode=\"numeric\" placeholder=\"0\"><\/div><\/div>\r\n      <\/div>\r\n      <div class=\"gwiba-grid-2\">\r\n        <div class=\"gwiba-field\"><label class=\"gwiba-lab\" for=\"claim2Accidents\">Number of accidents<\/label><input class=\"gwiba-input\" id=\"claim2Accidents\" type=\"text\" inputmode=\"numeric\"><\/div>\r\n        <div class=\"gwiba-field\"><label class=\"gwiba-lab\" for=\"claim2SettledCount\">Claims settled \u2014 number<\/label><input class=\"gwiba-input\" id=\"claim2SettledCount\" type=\"text\" inputmode=\"numeric\"><\/div>\r\n      <\/div>\r\n      <div class=\"gwiba-grid-2\">\r\n        <div class=\"gwiba-field\"><label class=\"gwiba-lab\" for=\"claim2SettledCost\">Claims settled \u2014 cost<\/label>\r\n          <div class=\"gwiba-money\"><span class=\"gwiba-cur\">KES<\/span><input class=\"gwiba-input\" id=\"claim2SettledCost\" type=\"text\" inputmode=\"numeric\" placeholder=\"0\"><\/div><\/div>\r\n        <div class=\"gwiba-field\"><label class=\"gwiba-lab\" for=\"claim2OutstandingCount\">Claims outstanding \u2014 number<\/label><input class=\"gwiba-input\" id=\"claim2OutstandingCount\" type=\"text\" inputmode=\"numeric\"><\/div>\r\n      <\/div>\r\n      <div class=\"gwiba-field\"><label class=\"gwiba-lab\" for=\"claim2OutstandingCost\">Claims outstanding \u2014 cost<\/label>\r\n        <div class=\"gwiba-money\"><span class=\"gwiba-cur\">KES<\/span><input class=\"gwiba-input\" id=\"claim2OutstandingCost\" type=\"text\" inputmode=\"numeric\" placeholder=\"0\"><\/div><\/div>\r\n      <div class=\"gwiba-hint\">More years of history? Share the rest with your advisor.<\/div>\r\n    <\/section>\r\n\r\n    <section class=\"gwiba-step\" data-step=\"7\">\r\n      <span class=\"gwiba-eyebrow\">Almost done<\/span>\r\n      <h2 class=\"gwiba-h\">Declaration<\/h2>\r\n      <p class=\"gwiba-sub\">Confirm the declaration to complete your proposal.<\/p>\r\n\r\n      <div class=\"gwiba-grid-2\">\r\n        <div class=\"gwiba-field\">\r\n          <label class=\"gwiba-lab\" for=\"completingName\">Name of person completing this form <span class=\"gwiba-req\">*<\/span><\/label>\r\n          <input class=\"gwiba-input\" id=\"completingName\" type=\"text\" placeholder=\"e.g. Jane Wanjiru\">\r\n          <div class=\"gwiba-err\" data-err=\"completingName\">Please enter a name.<\/div>\r\n        <\/div>\r\n        <div class=\"gwiba-field\">\r\n          <label class=\"gwiba-lab\" for=\"designation\">Designation <span style=\"font-weight:400;color:var(--muted);\">(optional)<\/span><\/label>\r\n          <input class=\"gwiba-input\" id=\"designation\" type=\"text\" placeholder=\"e.g. HR Manager\">\r\n        <\/div>\r\n      <\/div>\r\n\r\n      <div class=\"gwiba-field\">\r\n        <label class=\"gwiba-lab\">Your signature <span class=\"gwiba-req\">*<\/span><\/label>\r\n        <div class=\"gwiba-sigwrap\">\r\n          <canvas id=\"gwibaSigCanvas\" class=\"gwiba-sigcanvas\" width=\"700\" height=\"220\" aria-label=\"Draw your signature here with mouse or finger\"><\/canvas>\r\n          <span class=\"gwiba-sig-placeholder\" id=\"gwibaSigPlaceholder\">Sign here<\/span>\r\n        <\/div>\r\n        <div class=\"gwiba-sig-actions\">\r\n          <button type=\"button\" class=\"gwiba-btn gwiba-ghost\" id=\"gwibaSigClear\"><span class=\"gwiba-btxt\">Clear<\/span><\/button>\r\n        <\/div>\r\n        <div class=\"gwiba-hint\">Draw with your mouse, or your finger on a touchscreen. This is embedded into your proposal PDF.<\/div>\r\n        <div class=\"gwiba-err\" data-err=\"signature\">Please sign before submitting.<\/div>\r\n      <\/div>\r\n\r\n      <div class=\"gwiba-note\">\r\n        <svg viewBox=\"0 0 24 24\" fill=\"none\" stroke-width=\"2\" stroke-linecap=\"round\" stroke-linejoin=\"round\"><rect x=\"3\" y=\"11\" width=\"18\" height=\"11\" rx=\"2\"\/><path d=\"M7 11V7a5 5 0 0 1 10 0v4\"\/><\/svg>\r\n        <span>By signing and submitting, you declare that the statements set forth herein are true and complete, and that no material facts have been missed or misrepresented.<\/span>\r\n      <\/div>\r\n    <\/section>\r\n\r\n    <section class=\"gwiba-step\" data-step=\"8\">\r\n      <span class=\"gwiba-eyebrow\">Review<\/span>\r\n      <h2 class=\"gwiba-h\">Does everything look right?<\/h2>\r\n      <p class=\"gwiba-sub\">Take a quick look before we prepare your quotation.<\/p>\r\n      <div class=\"gwiba-summary\" id=\"gwibaSummary\"><!-- injected --><\/div>\r\n    <\/section>\r\n\r\n    <section class=\"gwiba-step\" data-step=\"done\">\r\n      <div class=\"gwiba-success\">\r\n        <div class=\"gwiba-scheck\">\r\n          <div class=\"disc\"><\/div>\r\n          <svg viewBox=\"0 0 24 24\"><path d=\"M20 6 9 17l-5-5\"\/><\/svg>\r\n        <\/div>\r\n        <h1>Thank You! \ud83c\udf89<\/h1>\r\n        <p>We've received your request. A Geminia Insurance advisor will prepare your quotation and contact you shortly.<\/p>\r\n        <p>If we need any additional information, we'll reach out to you.<\/p>\r\n        <button class=\"gwiba-btn gwiba-primary\" data-cta=\"return\">\r\n          <span class=\"gwiba-spin\"><\/span><span class=\"gwiba-btxt\">Return to Website<\/span>\r\n        <\/button>\r\n      <\/div>\r\n    <\/section>\r\n\r\n    <div class=\"gwiba-foot\" id=\"gwibaFoot\" style=\"display:none;\">\r\n      <button class=\"gwiba-btn gwiba-ghost\" id=\"gwibaPrev\">\r\n        <span class=\"gwiba-spin\"><\/span><span class=\"gwiba-btxt\">\u2190 Previous<\/span>\r\n      <\/button>\r\n      <button class=\"gwiba-btn gwiba-primary\" id=\"gwibaNext\">\r\n        <span class=\"gwiba-spin\"><\/span><span class=\"gwiba-btxt\">Next \u2192<\/span>\r\n      <\/button>\r\n    <\/div>\r\n\r\n    <button class=\"gwiba-exit\" id=\"gwibaExit\" type=\"button\" aria-label=\"Return to website\" title=\"Return to website\" style=\"display:none;\">\r\n      <svg viewBox=\"0 0 24 24\"><path d=\"M18 6 6 18M6 6l12 12\"\/><\/svg>\r\n    <\/button>\r\n    <div class=\"gwiba-confirm\" id=\"gwibaConfirm\" hidden role=\"dialog\" aria-modal=\"true\" aria-labelledby=\"gwibaConfirmTitle\">\r\n      <div class=\"gwiba-confirm-box\">\r\n        <div class=\"gwiba-confirm-ic\">\r\n          <svg viewBox=\"0 0 24 24\"><path d=\"M9 21H5a2 2 0 0 1-2-2V5a2 2 0 0 1 2-2h4\"\/><path d=\"m16 17 5-5-5-5\"\/><path d=\"M21 12H9\"\/><\/svg>\r\n        <\/div>\r\n        <h3 id=\"gwibaConfirmTitle\">Leave and return to the site?<\/h3>\r\n        <p>Your answers so far won't be saved.<\/p>\r\n        <div class=\"gwiba-confirm-actions\">\r\n          <button class=\"gwiba-btn gwiba-ghost\" id=\"gwibaStay\"><span class=\"gwiba-btxt\">Keep going<\/span><\/button>\r\n          <button class=\"gwiba-btn gwiba-primary\" id=\"gwibaLeave\"><span class=\"gwiba-spin\"><\/span><span class=\"gwiba-btxt\">Return to site<\/span><\/button>\r\n        <\/div>\r\n      <\/div>\r\n    <\/div>\r\n\r\n  <\/div>\r\n<\/div>\r\n\r\n<script src=\"https:\/\/cdn.jsdelivr.net\/npm\/pdf-lib@1.17.1\/dist\/pdf-lib.min.js\"><\/script>\r\n<script>\r\n(function(){\r\n  const root = document.getElementById('gwiba');\r\n  const ENDPOINT = (root.getAttribute('data-endpoint')||'').trim();\r\n  const RETURN_URL = 'https:\/\/geminia.co.ke';\r\n\r\n  const S = {step:1};\r\n  let hasSignature=false;\r\n  const TOTAL = 8;\r\n  const STEP_NAMES = {1:'Welcome',2:'Proposer',3:'Premises',4:'Prior insurance',5:'Employees',6:'Claims history',7:'Declaration',8:'Review'};\r\n\r\n  const $  = (s,c=root)=>c.querySelector(s);\r\n  const $$ = (s,c=root)=>Array.from(c.querySelectorAll(s));\r\n  const stepEl = n => $('.gwiba-step[data-step=\"'+n+'\"]');\r\n\r\n  function wireChoice(ch){\r\n    const input=ch.querySelector('input');\r\n    if(input.dataset.wired) return; 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if(!n.value.trim()){showErr('emp1Names',fail(n));} else clearErr('emp1Names');\r\n      if(!$('input[name=\"constantAllowanceIncluded\"]:checked')){showErr('constantAllowanceIncluded');ok=false;} else clearErr('constantAllowanceIncluded');\r\n    }\r\n    if(step===7){\r\n      const n=$('#completingName'); if(!n.value.trim()){showErr('completingName',fail(n));} else clearErr('completingName');\r\n      if(!hasSignature){ showErr('signature'); ok=false; } else clearErr('signature');\r\n    }\r\n    if(!ok){\r\n      const firstErr=$('.gwiba-err.show');\r\n      if(firstErr) firstErr.closest('.gwiba-field, .gwiba-step').scrollIntoView({behavior:'smooth',block:'center'});\r\n    }\r\n    return ok;\r\n  }\r\n\r\n  function escapeHtml(s){return String(s).replace(\/[&<>\"]\/g,c=>({'&':'&amp;','<':'&lt;','>':'&gt;','\"':'&quot;'}[c]));}\r\n  function buildReview(){\r\n    const g=$('#gwibaSummary');\r\n    const preExisting=$('input[name=\"preExistingConditions\"]:checked');\r\n    const allowance=$('input[name=\"constantAllowanceIncluded\"]:checked');\r\n\r\n    g.innerHTML=\r\n      block('\ud83d\udc64 Proposer',[\r\n        row('Name',$('#fullName').value||'\u2014'),\r\n        row('Email',$('#email').value||'\u2014'),\r\n        row('Location',$('#location').value||'\u2014')\r\n      ])\r\n      +block('\ud83d\udd0d Risk information',[\r\n        row('Pre-existing medical conditions',preExisting?preExisting.value:'\u2014')\r\n      ])\r\n      +block('\ud83d\udc65 Employees',[\r\n        row('Employee group 1',($('#emp1Names').value||'\u2014')+' \u2014 '+($('#emp1Occupation').value||'\u2014')),\r\n        row('Salaries include constant allowance',allowance?allowance.value:'\u2014')\r\n      ])\r\n      +block('\ud83d\udcde Declaration',[\r\n        row('Form completed by',$('#completingName').value||'\u2014'),\r\n        row('Signature',hasSignature?'\u2713 Captured':'Not captured')\r\n      ]);\r\n\r\n    function block(title,rows){return '<div class=\"gwiba-sblock\"><h4>'+title+'<\/h4>'+rows.filter(Boolean).join('')+'<\/div>';}\r\n    function row(k,v){return '<div class=\"gwiba-srow\"><span class=\"k\">'+k+'<\/span><span class=\"v\">'+escapeHtml(v)+'<\/span><\/div>';}\r\n  }\r\n\r\n  function render(){\r\n    const cur=$('.gwiba-step.active');\r\n    const next=stepEl(S.step);\r\n    if(cur && cur!==next){\r\n      cur.classList.add('leaving');\r\n      setTimeout(()=>{cur.classList.remove('active','leaving');next.classList.add('active');},260);\r\n    }else{\r\n      $$('.gwiba-step').forEach(s=>s.classList.remove('active'));\r\n      next.classList.add('active');\r\n    }\r\n    const isWelcome=S.step===1, isDone=S.step==='done';\r\n    const showChrome = !isWelcome && !isDone;\r\n    $('.gwiba-card').classList.toggle('gwiba-card--hero',isWelcome);\r\n    $('#gwibaProgress').classList.toggle('on',showChrome);\r\n    $('#gwibaFoot').style.display = showChrome ? 'flex' : 'none';\r\n    $('#gwibaExit').style.display = showChrome ? 'flex' : 'none';\r\n    $('#gwibaConfirm').hidden = true;\r\n    if(showChrome){\r\n      $('#gwibaStepNo').textContent=S.step;\r\n      $('#gwibaStepName').textContent=STEP_NAMES[S.step];\r\n      $('#gwibaFill').style.width=((S.step-1)\/(TOTAL-1))*100+'%';\r\n      const nextBtn=$('#gwibaNext');\r\n      nextBtn.querySelector('.gwiba-btxt').textContent = S.step===8 ? 'Get My Quote' : 'Next \u2192';\r\n      nextBtn.classList.toggle('wide', S.step===1);\r\n    }\r\n    root.scrollIntoView({behavior:'smooth',block:'start'});\r\n  }\r\n\r\n  function goTo(step){ S.step=step; render(); }\r\n  function next(){\r\n    if(typeof S.step==='number' && !validate(S.step)) return;\r\n    if(S.step===8){ submit(); return; }\r\n    if(S.step===7) buildReview();\r\n    goTo(S.step+1);\r\n  }\r\n  function prev(){ if(typeof S.step==='number' && S.step>2) goTo(S.step-1); }\r\n  function withLoading(btn,fn,delay=380){\r\n    btn.classList.add('loading');btn.disabled=true;\r\n    setTimeout(()=>{ try{fn();}finally{btn.classList.remove('loading');btn.disabled=false;} },delay);\r\n  }\r\n\r\n  function buildPayload(){\r\n    const g=id=>{const el=$('#'+id); return el? el.value.trim() : '';};\r\n    const radio=name=>{const el=$('input[name=\"'+name+'\"]:checked'); return el? el.value : '';};\r\n\r\n    const employees=[];\r\n    for(let i=1;i<=3;i++){\r\n      const names=g('emp'+i+'Names');\r\n      if(names) employees.push({names, occupation:g('emp'+i+'Occupation'), salary:g('emp'+i+'Salary').replace(\/[^\\d]\/g,'')});\r\n    }\r\n    const claimsHistory=[];\r\n    for(let i=1;i<=2;i++){\r\n      const year=g('claim'+i+'Year');\r\n      if(year) claimsHistory.push({\r\n        year, wages:g('claim'+i+'Wages').replace(\/[^\\d]\/g,''), accidents:g('claim'+i+'Accidents'),\r\n        settledCount:g('claim'+i+'SettledCount'), settledCost:g('claim'+i+'SettledCost').replace(\/[^\\d]\/g,''),\r\n        outstandingCount:g('claim'+i+'OutstandingCount'), outstandingCost:g('claim'+i+'OutstandingCost').replace(\/[^\\d]\/g,'')\r\n      });\r\n    }\r\n\r\n    return {\r\n      product_line:'WIBA Insurance',\r\n      submitted_at:new Date().toISOString(),\r\n      proposer:{\r\n        fullName:g('fullName'), kraPin:g('kraPin'), postalAddress:g('postalAddress'), postalCode:g('postalCode'),\r\n        town:g('town'), telephone:g('telephone'), faxNo:g('faxNo'), email:g('email'),\r\n        location:g('location'), natureOfBusiness:g('natureOfBusiness'),\r\n        periodFrom:g('periodFrom'), periodTo:g('periodTo')\r\n      },\r\n      premises:{\r\n        lawsApply:radio('lawsApply'), lawsDetail:g('lawsDetail'),\r\n        circularSaws:radio('circularSaws'), sawsDetail:g('sawsDetail'),\r\n        boilers:radio('boilers'), boilersDetail:g('boilersDetail'),\r\n        acidsChemicals:radio('acidsChemicals'), acidsDetail:g('acidsDetail'),\r\n        radioactive:radio('radioactive'), radioactiveDetail:g('radioactiveDetail')\r\n      },\r\n      priorInsurance:{\r\n        workmenCompProposed:radio('workmenCompProposed'),\r\n        proposalsDeclined:radio('proposalsDeclined'), declinedDetail:g('declinedDetail'),\r\n        increasedRatesRequired:radio('increasedRatesRequired'),\r\n        preExistingConditions:radio('preExistingConditions'), preExistingDetail:g('preExistingDetail')\r\n      },\r\n      employees,\r\n      constantAllowanceIncluded:radio('constantAllowanceIncluded'),\r\n      claimsHistory,\r\n      contact:{ completingName:g('completingName'), designation:g('designation'), signed:hasSignature }\r\n    };\r\n  }\r\n\r\n  async function buildSummaryPdf(p, sigDataUrl){\r\n    if(!window.PDFLib) return null;\r\n    const {PDFDocument, StandardFonts, rgb}=window.PDFLib;\r\n    const pdf=await PDFDocument.create();\r\n    const font=await pdf.embedFont(StandardFonts.Helvetica);\r\n    const bold=await pdf.embedFont(StandardFonts.HelveticaBold);\r\n    const W=595.28, H=841.89, margin=40, bottom=48;\r\n    const navy=rgb(0.224,0.212,0.502), acc=rgb(0.247,0.651,0.867), white=rgb(1,1,1),\r\n          mut=rgb(0.4,0.46,0.55), ink=rgb(0.086,0.157,0.239);\r\n    let pg, y;\r\n\r\n    function newPage(continued){\r\n      pg=pdf.addPage([W,H]);\r\n      pg.drawRectangle({x:0,y:H-34,width:W,height:34,color:navy});\r\n      pg.drawRectangle({x:0,y:H-36.4,width:W,height:2.4,color:acc});\r\n      pg.drawText('GEMINIA INSURANCE',{x:margin,y:H-22,size:15,font:bold,color:white});\r\n      pg.drawText('WIBA Insurance \u2014 Applicant Summary'+(continued?' (continued)':''),\r\n        {x:margin,y:H-31,size:9,font,color:white});\r\n      y=H-58;\r\n    }\r\n    function ensureSpace(need){ if(y-need<bottom) newPage(true); }\r\n    function head(t){\r\n      ensureSpace(26);\r\n      pg.drawText(t.toUpperCase(),{x:margin,y,size:10,font:bold,color:navy});\r\n      pg.drawLine({start:{x:margin,y:y-4},end:{x:W-margin,y:y-4},thickness:1,color:acc});\r\n      y-=18;\r\n    }\r\n    function kv(k,v){\r\n      ensureSpace(15);\r\n      pg.drawText(k,{x:margin+2,y,size:9,font,color:mut});\r\n      pg.drawText(String(v||'\u2014'),{x:230,y,size:9.5,font:bold,color:ink,maxWidth:W-230-margin});\r\n      y-=15;\r\n    }\r\n    function money(v){ return v? 'KES '+Number(v).toLocaleString('en-US') : '\u2014'; }\r\n    function para(t,size=9){\r\n      const words=String(t).split(' '); const maxW=W-2*margin; let line='';\r\n      words.forEach(w=>{\r\n        const test=line?line+' '+w:w;\r\n        if(font.widthOfTextAtSize(test,size)>maxW){\r\n          ensureSpace(13); pg.drawText(line,{x:margin,y,size,font,color:mut}); y-=13; line=w;\r\n        }else line=test;\r\n      });\r\n      if(line){ ensureSpace(13); pg.drawText(line,{x:margin,y,size,font,color:mut}); y-=13; }\r\n    }\r\n\r\n    newPage(false);\r\n\r\n    head('Proposer');\r\n    kv('Name in full',p.proposer.fullName); kv('KRA PIN',p.proposer.kraPin);\r\n    kv('Postal address',(p.proposer.postalAddress||'\u2014')+' '+(p.proposer.postalCode||'')+', '+(p.proposer.town||'\u2014'));\r\n    kv('Telephone \/ Fax',(p.proposer.telephone||'\u2014')+' \/ '+(p.proposer.faxNo||'\u2014'));\r\n    kv('Email',p.proposer.email); kv('Physical address\/location',p.proposer.location);\r\n    kv('Nature of business',p.proposer.natureOfBusiness);\r\n    kv('Period of insurance',(p.proposer.periodFrom||'\u2014')+' to '+(p.proposer.periodTo||'\u2014'));\r\n\r\n    y-=6; head('Premises & machinery');\r\n    kv('Laws\/regulations apply',p.premises.lawsApply+(p.premises.lawsDetail?(' \u2014 '+p.premises.lawsDetail):''));\r\n    kv('Circular saws\/machinery',p.premises.circularSaws+(p.premises.sawsDetail?(' \u2014 '+p.premises.sawsDetail):''));\r\n    kv('Boilers',p.premises.boilers+(p.premises.boilersDetail?(' \u2014 '+p.premises.boilersDetail):''));\r\n    kv('Acids\/gases\/chemicals\/explosives',p.premises.acidsChemicals+(p.premises.acidsDetail?(' \u2014 '+p.premises.acidsDetail):''));\r\n    kv('Radioisotopes\/radioactive substances',p.premises.radioactive+(p.premises.radioactiveDetail?(' \u2014 '+p.premises.radioactiveDetail):''));\r\n\r\n    y-=6; head('Prior insurance & health');\r\n    kv('Workmen\\'s comp\/WIBA policy proposed',p.priorInsurance.workmenCompProposed);\r\n    kv('Proposals declined\/withdrawn',p.priorInsurance.proposalsDeclined+(p.priorInsurance.declinedDetail?(' \u2014 '+p.priorInsurance.declinedDetail):''));\r\n    kv('Increased rates required',p.priorInsurance.increasedRatesRequired);\r\n    kv('Pre-existing medical conditions',p.priorInsurance.preExistingConditions+(p.priorInsurance.preExistingDetail?(' \u2014 '+p.priorInsurance.preExistingDetail):''));\r\n\r\n    y-=6; head('Employee schedule');\r\n    (p.employees||[]).forEach((e,i)=>{\r\n      kv('Group '+(i+1),e.names+(e.occupation?(' \u2014 '+e.occupation):'')+(e.salary?(' \u2014 '+money(e.salary)+'\/yr'):''));\r\n    });\r\n    kv('Salaries include constant allowance',p.constantAllowanceIncluded);\r\n\r\n    if((p.claimsHistory||[]).length){\r\n      y-=6; head('Claims history');\r\n      p.claimsHistory.forEach(c=>{\r\n        kv('Year '+c.year,'Wages '+money(c.wages)+' \u00b7 Accidents '+(c.accidents||'\u2014'));\r\n        kv('  Settled \/ Outstanding',(c.settledCount||'0')+' claims ('+money(c.settledCost)+') \/ '+(c.outstandingCount||'0')+' claims ('+money(c.outstandingCost)+')');\r\n      });\r\n    }\r\n\r\n    y-=6; head('Declaration');\r\n    kv('Form completed by',p.contact.completingName); kv('Designation',p.contact.designation);\r\n    para('I\/We do hereby declare that to the best of my knowledge and belief that the statements set forth herein are true and complete. Further, no material facts have been missed or mis-represented. I\/we agree that the proposal together with any other information supplied shall form the basis of any contract.');\r\n    y-=8;\r\n    ensureSpace(64);\r\n    pg.drawText('Signature:',{x:margin,y,size:9,font,color:mut});\r\n    if(sigDataUrl){\r\n      try{\r\n        const sigBytes=await fetch(sigDataUrl).then(r=>r.arrayBuffer());\r\n        const sigImg=await pdf.embedPng(sigBytes);\r\n        const dims=sigImg.scaleToFit(170,54);\r\n        pg.drawImage(sigImg,{x:margin+68,y:y-dims.height+9,width:dims.width,height:dims.height});\r\n        y-=(dims.height+16);\r\n      }catch(err){\r\n        pg.drawText('(signature image could not be embedded)',{x:margin+68,y,size:8.5,font,color:mut}); y-=16;\r\n      }\r\n    }else{\r\n      pg.drawText('Not captured online',{x:margin+68,y,size:9.5,font,color:ink}); y-=16;\r\n    }\r\n    kv('Date',new Date().toLocaleDateString('en-GB'));\r\n\r\n    pg.drawText('Figures are applicant estimates, subject to underwriting review and policy terms & conditions.',\r\n      {x:margin,y:30,size:8,font,color:mut});\r\n\r\n    return await pdf.saveAsBase64();\r\n  }\r\n\r\n  async function submit(){\r\n    const btn=$('#gwibaNext');\r\n    btn.classList.add('loading');btn.disabled=true;$('#gwibaPrev').disabled=true;\r\n    const finish=()=>{ btn.classList.remove('loading');btn.disabled=false;$('#gwibaPrev').disabled=false; goTo('done'); };\r\n    const p=buildPayload();\r\n    const sigCanvas=$('#gwibaSigCanvas');\r\n    const sigDataUrl = hasSignature && sigCanvas ? sigCanvas.toDataURL('image\/png') : '';\r\n    let pdfBase64=null;\r\n    try{ pdfBase64=await buildSummaryPdf(p, sigDataUrl); }\r\n    catch(err){ console.warn('PDF build skipped:',err); }\r\n    const body={ lead:p, pdfBase64,\r\n      filename:'WIBA_Insurance_'+((p.proposer.fullName||'Proposal').replace(\/[^\\w]+\/g,'_').slice(0,40))+'.pdf' };\r\n    if(!ENDPOINT){ setTimeout(finish,1200); return; }\r\n    fetch(ENDPOINT,{\r\n      method:'POST',\r\n      headers:{'Content-Type':'text\/plain;charset=utf-8'},\r\n      body:JSON.stringify(body)\r\n    }).then(finish).catch(finish);\r\n  }\r\n\r\n  $('[data-cta=\"start\"]').addEventListener('click',function(){ withLoading(this,()=>goTo(2),420); });\r\n  const confirmEl=$('#gwibaConfirm');\r\n  $('#gwibaExit').addEventListener('click',()=>{ confirmEl.hidden=false; $('#gwibaStay').focus(); });\r\n  $('#gwibaStay').addEventListener('click',()=>{ confirmEl.hidden=true; $('#gwibaExit').focus(); });\r\n  $('#gwibaLeave').addEventListener('click',function(){ withLoading(this,()=>{ window.top.location.href=RETURN_URL; },500); });\r\n  root.addEventListener('keydown',e=>{ if(e.key==='Escape' && !confirmEl.hidden){ confirmEl.hidden=true; $('#gwibaExit').focus(); } });\r\n  $('[data-cta=\"return\"]').addEventListener('click',function(){ withLoading(this,()=>{ window.top.location.href=RETURN_URL; },500); });\r\n  $('#gwibaNext').addEventListener('click',next);\r\n  $('#gwibaPrev').addEventListener('click',prev);\r\n\r\n  render();\r\n})();\r\n<\/script>\r\n<\/div>\r\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Step 1 of 8 Welcome Protect Your Employees in Minutes Answer a few questions about your business and employees, and we&#8217;ll prepare your WIBA Insurance proposal for a Geminia advisor to quote. Get Started \u2192 About you Proposer&#8217;s details Part 1 of the official Geminia WIBA Insurance proposal form \u2014 indemnity to the employer under [&hellip;]<\/p>\n","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-1593","page","type-page","status-publish","hentry"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.0 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>WIBA Form - Geminia Insurance<\/title>\n<meta name=\"robots\" content=\"noindex, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"WIBA Form - Geminia Insurance\" \/>\n<meta property=\"og:description\" content=\"Step 1 of 8 Welcome Protect Your Employees in Minutes Answer a few questions about your business and employees, and we&#8217;ll prepare your WIBA Insurance proposal for a Geminia advisor to quote. 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