80 lines
4.0 KiB
PHP
80 lines
4.0 KiB
PHP
<!-- Contractor's All Risk Policy (CAR) -->
|
|
|
|
<hr>
|
|
|
|
<div class="form-row custom_fields">
|
|
<!-- Sum Insured -->
|
|
<div class="form-group col-md-3">
|
|
<label for="sum_insured">Sum Insured:</label>
|
|
<input type="text" class="form-control" id="sum_insured" name="sum_insured"
|
|
value="<?= isset($lead_edit_data['sum_insured']) ? htmlspecialchars($lead_edit_data['sum_insured']) : ''; ?>">
|
|
</div>
|
|
|
|
<!-- Policy Period -->
|
|
<div class="form-group col-md-3">
|
|
<label for="policy_period">Policy Period:</label>
|
|
<select class="form-control" id="policy_period" name="policy_period">
|
|
<option value="">Select Policy Period</option>
|
|
<?php for ($i = 1; $i <= 24; $i++):
|
|
$selected = (isset($lead_edit_data['policy_period']) && $lead_edit_data['policy_period'] == "$i Month") ? 'selected' : ''; ?>
|
|
<option value="<?= $i . " Month" ?>" <?= $selected ?>><?= $i ?> Month</option>
|
|
<?php endfor; ?>
|
|
</select>
|
|
</div>
|
|
|
|
<!-- Maintenance Period -->
|
|
<div class="form-group col-md-3">
|
|
<label for="maintenance_period">Maintenance Period:</label>
|
|
<select class="form-control" id="maintenance_period" name="maintenance_period">
|
|
<option value="">Select Maintenance Period</option>
|
|
<?php for ($i = 6; $i <= 24; $i += 2):
|
|
$selected = (isset($lead_edit_data['maintenance_period']) && $lead_edit_data['maintenance_period'] == "$i Month") ? 'selected' : ''; ?>
|
|
<option value="<?= $i . " Month" ?>" <?= $selected ?>><?= $i ?> Month</option>
|
|
<?php endfor; ?>
|
|
</select>
|
|
</div>
|
|
|
|
<!-- Project Start Date -->
|
|
<div class="form-group col-md-3">
|
|
<label for="project_start_date">Project Start Date:</label>
|
|
<input type="text" class="form-control" id="project_start_date" name="project_start_date" placeholder="DD/MM/YYYY"
|
|
value="<?= isset($lead_edit_data['project_start_date']) ? htmlspecialchars($lead_edit_data['project_start_date']) : ''; ?>">
|
|
</div>
|
|
|
|
<!-- Was the Project Earlier Insured? -->
|
|
<div class="form-group col-md-3">
|
|
<label>Was the Project earlier insured?</label>
|
|
<div>
|
|
<input type="radio" id="insured_yes" name="insured" value="yes"
|
|
<?= (isset($lead_edit_data['insured']) && $lead_edit_data['insured'] == 'yes') ? 'checked' : ''; ?>>
|
|
<label for="insured_yes">Yes</label>
|
|
<input type="radio" id="insured_no" name="insured" value="no"
|
|
<?= (isset($lead_edit_data['insured']) && $lead_edit_data['insured'] == 'no') ? 'checked' : ''; ?>>
|
|
<label for="insured_no">No</label>
|
|
</div>
|
|
</div>
|
|
|
|
<!-- Project Exposure -->
|
|
<div class="form-group col-md-6">
|
|
<label>Does the project have exposure to Underground Operations, Tunnels, Hilly areas, Offshore, Wet Risks, Oil Rigs, or Hydro projects?</label>
|
|
<div>
|
|
<input type="radio" id="exposure_yes" name="exposure" value="yes"
|
|
<?= (isset($lead_edit_data['exposure']) && $lead_edit_data['exposure'] == 'yes') ? 'checked' : ''; ?>>
|
|
<label for="exposure_yes">Yes</label>
|
|
<input type="radio" id="exposure_no" name="exposure" value="no"
|
|
<?= (isset($lead_edit_data['exposure']) && $lead_edit_data['exposure'] == 'no') ? 'checked' : ''; ?>>
|
|
<label for="exposure_no">No</label>
|
|
</div>
|
|
</div>
|
|
|
|
<!-- Address -->
|
|
<div class="form-group col-md-3">
|
|
<label for="pinCode">Pin Code</label>
|
|
<input type="text" class="form-control" id="pinCode" name="pincode" value="<?= isset($lead_edit_data['pincode']) ? htmlspecialchars($lead_edit_data['pincode']) : ''; ?>">
|
|
</div>
|
|
<div class="form-group col-md-3">
|
|
<label for="address">Address:</label>
|
|
<textarea class="form-control" id="address" name="address"><?= isset($lead_edit_data['address']) ? htmlspecialchars($lead_edit_data['address']) : ''; ?></textarea>
|
|
</div>
|
|
</div>
|