?? burdenins.jsp
字號:
<%@ page contentType="text/html; charset=gb2312" language="java" import="java.sql.*" errorPage="" %>
<!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.01 Transitional//EN" "http://www.w3.org/TR/html4/loose.dtd">
<html>
<head>
<meta http-equiv="Content-Type" content="text/html; charset=gb2312">
<title>無標(biāo)題文檔</title>
</head>
<body>
<jsp:include flush="true" page="header.jsp" />
<br>
<form method="post" action="vehicleinsurancelog.jsp">
<jsp:include page="show.jsp" />
<table align="right" bgcolor="#00CCFF" width="20%"><tr><td><img align="middle" src="showphto"></td></tr></table>
<table align="center" width="40%">
<tr align="left">
<td colspan="2"> <font size="+2" >Please fill in the form <br></font><font size="+1" color="#FF0000"> (Must fill if the item with *)</font></td>
</tr>
<tr>
<td>
<div align="center">標(biāo) 的 號:</div></td><td><INPUT type="text" name="target_id" size="30">
</td>
</tr>
<tr>
<td>
<div align="center">客 戶 號:</div></td><td><INPUT type="text" name="custom_id" size="30" >
</td>
</tr>
<tr>
<td>
<div align="center">聯(lián)系人號:</div></td>
<td><INPUT type="text" name="person_id" size="30" >
</td>
</tr>
<tr><td><div align="center">累計賠償限額</div></td><td><input type="text" name="total_rep" size="30"> 元</td>
</tr>
<tr><td><div align="center">每次事故賠償限額</div></td><td><input type="text" size="30" name="percase_rep"></td>
</tr>
<tr><td><div align="center"> 每人傷亡賠償限額1</div></td><td><input type="text" name="perdeath1" size="30"> </td>
</tr>
<tr><td><div align="center">傷亡賠償限額1的人數(shù)</div></td><td><input type="text" name="person1" size="30"> 噸</td>
</tr>
<tr><td><div align="center">每人傷亡賠償限額2</div></td><td><input type="text" name="perdeath2" size="30"> 元</td>
</tr>
<tr><td><div align="center">傷亡賠償限額2的人數(shù)</div></td><td><input type="text" size="30" name="person2 "></td>
</tr>
<tr><td><div align="center"> 每人醫(yī)療費賠償限額1</div></td><td><input type="text" name="perservicefee1" size="30"> </td>
</tr>
<tr><td><div align="center">醫(yī)療賠償限額1的人數(shù)</div></td><td><input type="text" name="personfee1" size="30"> 噸</td>
</tr>
<tr><td><div align="center">每人醫(yī)療費賠償限額2</div></td><td><input type="text" size="30" name="perservicefee2"></td>
</tr>
<tr><td><div align="center">醫(yī)療賠償限額2的人數(shù)</div></td><td><input type="text" name="perservicelose" size="30"> </td>
</tr>
<tr><td><div align="center">每人醫(yī)療費每次事故免賠額 </div></td><td><input type="text" name="lose_of_rate" size="30"> 噸</td>
</tr>
<tr><td><div align="center">每人醫(yī)療費每次事故免賠率</div></td><td><input type="text" name="specialitem" size="30"> 噸</td>
</tr>
<tr><td><input type="submit" name="submit"></td></tr>
</table>
</form>
</body>
</html>
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