<div class="form-info">
<div class="box box--bordered">
<div class="box__content">
<h3 class="headline headline--headline-1">Gleich ausfüllen und mehr Infos bekommen
</h3>
<form class="form">
<div class="form__inner">
<fieldset class="form-group form-group--fullwide">
<legend class="label u-hidden-visually">Mitgliedschaft</legend>
<div class="form-group__inner">
<label class="radio radio--nextline">
<input class="radio__input" type="radio" value="membership" required="required" id="radio-6fba" name="subject"/><span class="radio__indicator"></span><span class="radio__label">Ja, ich möchte Mitglied der Krankenkasse hkk werden.</span>
</label>
<label class="radio radio--nextline">
<input class="radio__input" type="radio" value="info" required="required" id="radio-503d" name="subject"/><span class="radio__indicator"></span><span class="radio__label">Ja, ich möchte mehr über die Krankenkasse hkk wissen. Senden Sie mir bitte Infomaterial zu.</span>
</label>
</div>
</fieldset>
<fieldset class="form-group form-group--fullwide">
<legend class="label label--required label--large">Ich bin</legend>
<div class="form-group__inner">
<label class="radio radio--nextline">
<input class="radio__input" type="radio" value="employee" required="required" id="radio-471d" name="status"/><span class="radio__indicator"></span><span class="radio__label">Arbeitnehmer oder selbstständig tätig.</span>
</label>
<label class="radio radio--nextline">
<input class="radio__input" type="radio" value="student" required="required" id="radio-732d" name="status"/><span class="radio__indicator"></span><span class="radio__label">Student oder sonstiges (z.B. Künstler, Beamter).</span>
</label>
</div>
</fieldset>
<fieldset class="form-group form-group--fullwide">
<legend class="label label--required label--large">Persönliche Informationen</legend>
<div class="form-group__inner">
<label class="radio">
<input class="radio__input" type="radio" value="female" id="radio-3b62" name="gender"/><span class="radio__indicator"></span><span class="radio__label">Frau</span>
</label>
<label class="radio">
<input class="radio__input" type="radio" value="male" id="radio-5887" name="gender"/><span class="radio__indicator"></span><span class="radio__label">Herr</span>
</label>
</div>
</fieldset>
<fieldset class="form-group form-group--fullwide form-group--inline">
<legend class="label u-hidden-visually">Name</legend>
<div class="form-group__inner">
<input class="input input--text" type="text" placeholder="Vorname*" required="required" autocomplete="fname" id="input-9b2a" name="name" />
<input class="input input--text" type="text" placeholder="Nachname*" required="required" autocomplete="lname" id="input-2923" name="name" />
</div>
</fieldset>
<div class="form-group form-group--fullwide">
<label class="label" for="birthdate">Geburtsdatum</label>
<div class="form-group__inner">
<input class="input input--date" type="date" placeholder="Geburtsdatum*" required="required" autocomplete="birthdate" id="birthdate" name="birthdate" />
</div>
</div>
<div class="form-group form-group--fullwide">
<label class="label u-hidden-visually" for="address-1">Straße, Hausnummer</label>
<div class="form-group__inner">
<input class="input input--text" type="text" placeholder="Straße, Nr.*" required="required" autocomplete="address-line1" id="address-1" name="address-1" />
</div>
</div>
<fieldset class="form-group form-group--fullwide form-group--inline">
<legend class="label u-hidden-visually">PLZ und Ort</legend>
<div class="form-group__inner">
<input class="input input--text input--25" type="text" placeholder="PLZ*" required="required" autocomplete="zipcode" id="input-5436" name="address-2" />
<input class="input input--text input--75" type="text" placeholder="Ort*" required="required" autocomplete="city" id="input-b95f" name="address-2" />
</div>
</fieldset>
<fieldset class="form-group form-group--fullwide form-group--inline">
<legend class="label u-hidden-visually">E-Mail-Addresse und Telefonnummer</legend>
<div class="form-group__inner">
<input class="input input--email" type="email" placeholder="E-Mail-Adresse" autocomplete="email" id="input-39c5" name="contact" />
<input class="input input--tel" type="tel" placeholder="Telefonnummer" autocomplete="telephone" id="input-4301" name="contact" />
</div>
</fieldset>
<div class="form-group form-group--fullwide">
<label class="label u-hidden-visually" for="privacy-policy">Datenschutzerklärung</label>
<div class="form-group__inner">
<label class="checkbox">
<input class="checkbox__input" type="checkbox" value="1" required="required" id="privacy-policy" name="privacy-policy"/><span class="checkbox__indicator"></span><span class="checkbox__label"><span class="formatted-text">Ich akzeptiere die <a href="#">Datenschutzerklärung</a>.*</span></span>
</label>
</div>
</div>
<div class="form__submit">
<input class="button button--blue" type="submit" value="Abschicken" />
</div>
</div>
</form>
</div>
</div>
</div>
-
//- Prepare attr object
attr = attr || {};
attr.class = classList(attr.class);
//- Form info
.form-info&attributes(attr)
!= include('@box--info-form')
/* No context defined for this component. */
.form-info {
margin: 0 auto;
max-width: 83rem;
&__form {
margin: 0;
}
}
There are no notes for this item.