@extends('backend.admin-withouterrmaster')
@section('site-title')
    {{__('Dashboard')}}
@endsection
@section('content')
 <!-- Content wrapper -->
          <div class="content-wrapper">
            <!-- Content -->

            <div class="container-xxl flex-grow-1 container-p-y">
              <h4 class="fw-bold py-3 mb-4"><span class="text-muted fw-light">Insurance /</span> Health Insurance</h4>
				 @if(session('success'))
			<div class="alert alert-success alert-dismissable custom-success-box">
				 <a href="#" class="close" data-dismiss="alert" aria-label="close">&times;</a>
				 <strong> {{session('success')}} </strong>
			  </div>
			@endif
              <div class="row">
                <div class="col-md-12">

                  <div class="card mb-4">


                    <hr class="my-0" />
                    <div class="card-body">
                     <form action="{{ route('superadmin.health_insurance_process_submit') }}" enctype="multipart/form-data" method="POST" >
					  @csrf
					  <input type="hidden" class="form-control"  name="userid" id="userid"  value="{{$user_details->id}}" />
					  <input type="hidden" class="form-control"  name="query_for" id="query_for"  value="Self" />
						
						<div class="row mb-3">
                          <label class="col-sm-2 col-form-label" for="basic-default-name">Full Name <sup style="color:red;">*</sup></label>
                          <div class="col-sm-10">
                            <input type="text" value="{{ old('full_name') ? old('full_name') : Session()->get('enquiry_username') }}" name="full_name" class="form-control" id="full_name" placeholder="" />
							@if($errors->has('full_name'))
									<div class="error">{{ $errors->first('full_name') }}</div>
							@endif
						  </div>
                        </div>

                         <div class="row mb-3">
                          <label class="col-sm-2 col-form-label" for="basic-default-name">Email id <sup style="color:red;">*</sup> </label>
                          <div class="col-sm-10">
                            <input type="email" name="email" class="form-control" value="{{ old('email') ? old('email') : Session()->get('enquiry_useremail') }}"  id="emailid" placeholder="" />
							@if($errors->has('email'))
									<div class="error">{{ $errors->first('email') }}</div>
							@endif
						  </div>
                        </div>

                        <div class="row mb-3">
                          <label class="col-sm-2 col-form-label" for="basic-default-phone">Contact No.<sup style="color:red;">*</sup></label>
                          <div class="col-sm-10">
                            <input
                              type="tel"
                              id="contact_no"
							  name="contact_no"
							  value="{{ old('contact_no') ? old('contact_no') : Session()->get('enquiry_userphone') }}"
                              class="form-control phone-mask"
                              placeholder=""
                            />
							@if($errors->has('contact_no'))
									<div class="error">{{ $errors->first('contact_no') }}</div>
							@endif
                          </div>
                        </div>
						
						<div class="row mb-3">
                          <label class="col-sm-2 col-form-label" for="basic-default-name">Pin Code<sup style="color:red;">*</sup></label>
                          <div class="col-sm-10">
                            <input
                            type="tel"
                            class="form-control"
                            id="pin_code"
                            name="pin_code"
                            value="{{ old('pin_code') }}"
                            placeholder=""
                            maxlength="6"
                            onkeyup="if (/\D/g.test(this.value)) this.value = this.value.replace(/\D/g,'')"
                          />
							@if($errors->has('pin_code'))
									<div class="error">{{ $errors->first('pin_code') }}</div>
							@endif
						  </div>
                        </div>

                       
                     <div class="row mb-3">
                      <label class="col-sm-2 col-form-label" for="city">Type of Insurance<sup style="color:red;">*</sup></label>
                      <div class="col-sm-10">
                        <select id="type_of_insurance" class="select2 form-select" name="type_of_insurance">
                        <option value="">Select Type of Insurance</option>
                        <option {{ old('type_of_insurance')=='Individual Health Insurance' ? 'selected' : '' }} value="Individual Health Insurance">Individual Health Insurance</option>
                        <option {{ old('type_of_insurance')=='Family Floater Health Insurance' ? 'selected' : '' }} value="Family Floater Health Insurance">Family Floater Health Insurance</option>
                        <option {{ old('type_of_insurance')=='Group Health Insurance' ? 'selected' : '' }} value="Group Health Insurance">Group Health Insurance</option>

                        <!-- <option {{ old('type_of_insurance')=='Individual' ? 'selected' : '' }} value="Individual"> Individual </option>
						<option { old('type_of_insurance')=='Family floater' ? 'selected' : '' }} value="Family floater"> Family floater</option>
						<option { old('type_of_insurance')=='Group' ? 'selected' : '' }} value="Group"> Group </option>
                       -->
          </select>
                      @if($errors->has('type_of_insurance'))
                        <div class="error">{{ $errors->first('type_of_insurance') }}</div>
                      @endif
                    </div>
                   </div>
						<div class="row mb-3">
                          <label class="col-sm-2 col-form-label" for="basic-default-name">Coverage required<sup style="color:red;">*</sup></label>
                          <div class="col-sm-10">
                            <input type="text" name="coverage_required" value="{{ old('coverage_required') }}" class="form-control" id="basic-default-name" placeholder="" />
							@if($errors->has('coverage_required'))
									<div class="error">{{ $errors->first('coverage_required') }}</div>
							@endif
						  </div>
                        </div>
						
						<div class="row mb-3">
                          <label class="col-sm-2 col-form-label" for="basic-default-name">Age of insured<sup style="color:red;">*</sup></label>
                          <div class="col-sm-10">
                            <input type="text" name="age" value="{{ old('age') }}" class="form-control" id="basic-default-name" placeholder="" />
							@if($errors->has('age'))
									<div class="error">{{ $errors->first('age') }}</div>
							@endif
						  </div>
                        </div>
						
						


						<div class="row mb-3">

					<div class="col-xl-12">

				   <div class="row justify-content-end">
                          <div class="col-sm-12">
                            <button type="submit" class="btn btn-primary">Submit</button>
                          </div>
                        </div>
                </div>
				</form>
                    </div>
                    <!-- /Account -->
                  </div>


                </div>
              </div>
            </div>
            <!-- / Content -->

      
@endsection