Simple Data Entry page flow for Vehicle Insurance

I am looking for simple but elegant page for data entry page flow for auto insurance business. Attached file has the details. I have created database design as well (Name tables, fields, datatypes and keys). Same must be used. Attached screen shows how data entry fields will be presented to the end user. It includes Screen validation and logic as well. "List of Values" will be one big table and values of all the dropdowns and radio buttons etc. will come from this one table. (I will provide data of this table). This table will simplify development and maintenance of the code. Use jQuery and Bootstrap. I am NOT expecting VISUAL ENHANCEMENTS. No advanced features... Just Form and form submission. For List of Values, develop ONE FUNCTION to fetch the list and use the same function through out the list. I will provide FTP access to my server (Linux) and MySQL DB. It should work on my server. You can do initial work on your local. IMPORTANT: Only bid if you can finish it in budget and on time. (3 DAYS - No 4th day). You may update me with progress during the 3 days, so that I can feel comfortable that you are going on track. My budget is around 100 USD. I will not consider bids higher than that.