43 lines
1.7 KiB
PHP
43 lines
1.7 KiB
PHP
<hr>
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<div class="form-row custom_fields">
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<!-- Business Activity -->
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<div class="form-group col-md-3">
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<label for="business_activity">Business Activity</label>
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<input type="text" class="form-control" id="business_activity" name="business_activity">
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</div>
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<!-- Basis of Policy -->
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<div class="form-group col-md-4">
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<label>Basis of Policy</label>
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<div>
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<div class="form-check form-check-inline">
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<input class="form-check-input" type="radio" id="claims_made" name="basis_of_policy" value="Claims Made Basis">
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<label class="form-check-label" for="claims_made">Claims Made Basis</label>
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</div>
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<div class="form-check form-check-inline">
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<input class="form-check-input" type="radio" id="occurrence_basis" name="basis_of_policy" value="Occurrence Basis">
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<label class="form-check-label" for="occurrence_basis">Occurrence Basis</label>
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</div>
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</div>
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</div>
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<!-- Limit of Indemnity -->
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<div class="form-group col-md-3">
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<label for="limit_of_indemnity">Limit of Indemnity</label>
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<input type="text" class="form-control" id="limit_of_indemnity" name="limit_of_indemnity">
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</div>
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<!-- Retro-active Date -->
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<div class="form-group col-md-3">
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<label for="retro_active_date">Retro-active Date</label>
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<input type="text" class="form-control" id="retro_active_date" name="retro_active_date" placeholder="DD/MM/YYYY">
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</div>
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<!-- Address of the Insured -->
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<div class="form-group col-md-6">
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<label for="address">Address of the Insured</label>
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<textarea class="form-control" id="address" name="address" rows="1"></textarea>
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</div>
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</div>
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