94 lines
4.8 KiB
PHP
94 lines
4.8 KiB
PHP
<hr>
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<div class="form-row custom_fields">
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<!-- Risk Location -->
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<div class="form-group col-md-6">
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<label>Risk Location</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="single" name="risk_location" value="Single"
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<?= isset($lead_edit_data['risk_location']) && $lead_edit_data['risk_location'] == 'Single' ? 'checked' : ''; ?>>
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<label class="form-check-label" for="single">Single</label>
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</div>
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<div class="form-check form-check-inline">
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<input class="form-check-input" type="radio" id="multi_floater" name="risk_location" value="multi_with_floter"
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<?= isset($lead_edit_data['risk_location']) && $lead_edit_data['risk_location'] == 'multi_with_floter' ? 'checked' : ''; ?>>
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<label class="form-check-label" for="multi_floater">Multi With Floater</label>
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</div>
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<div class="form-check form-check-inline">
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<input class="form-check-input" type="radio" id="multi_no_floater" name="risk_location" value="multi_without_floter"
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<?= isset($lead_edit_data['risk_location']) && $lead_edit_data['risk_location'] == 'multi_without_floter' ? 'checked' : ''; ?>>
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<label class="form-check-label" for="multi_no_floater">Multi without Floater</label>
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</div>
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</div>
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</div>
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<!-- Nature of Business -->
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<div class="form-group col-md-3">
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<label for="nature_of_business">Nature of Business</label>
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<input type="text" class="form-control" id="nature_of_business" name="nature_of_business"
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value="<?= isset($lead_edit_data['nature_of_business']) ? htmlspecialchars($lead_edit_data['nature_of_business']) : ''; ?>">
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</div>
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<!-- Retro-active Date -->
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<div class="form-group col-md-3">
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<label for="retro_active_date">Retro-active Date</label>
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<input type="text" class="form-control" id="retro_active_date" name="retro_active_date" placeholder="DD/MM/YYYY"
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value="<?= isset($lead_edit_data['retro_active_date']) ? htmlspecialchars($lead_edit_data['retro_active_date']) : ''; ?>">
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</div>
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<!-- Annual Turnover -->
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<div class="form-group col-md-3">
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<label for="annual_turnover">Annual Turnover</label>
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<input type="text" class="form-control" id="annual_turnover" name="annual_turnover"
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value="<?= isset($lead_edit_data['annual_turnover']) ? htmlspecialchars($lead_edit_data['annual_turnover']) : ''; ?>">
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</div>
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<!-- Territory -->
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<div class="form-group col-md-3">
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<label for="territory">Territory</label>
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<input type="text" class="form-control" id="territory" name="territory"
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value="<?= isset($lead_edit_data['territory']) ? htmlspecialchars($lead_edit_data['territory']) : ''; ?>">
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</div>
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<!-- Jurisdiction -->
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<div class="form-group col-md-3">
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<label for="jurisdiction">Jurisdiction</label>
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<input type="text" class="form-control" id="jurisdiction" name="jurisdiction"
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value="<?= isset($lead_edit_data['jurisdiction']) ? htmlspecialchars($lead_edit_data['jurisdiction']) : ''; ?>">
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</div>
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<!-- AOA (Any One Accident) -->
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<div class="form-group col-md-3">
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<label for="aoa">AOA (Any One Accident)</label>
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<input type="text" class="form-control" id="aoa" name="aoa"
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value="<?= isset($lead_edit_data['aoa']) ? htmlspecialchars($lead_edit_data['aoa']) : ''; ?>">
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</div>
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<!-- AOY (Any One Year) -->
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<div class="form-group col-md-3">
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<label for="aoy">AOY (Any One Year)</label>
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<input type="text" class="form-control" id="aoy" name="aoy"
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value="<?= isset($lead_edit_data['aoy']) ? htmlspecialchars($lead_edit_data['aoy']) : ''; ?>">
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</div>
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<!-- Designated Premises -->
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<div class="form-group col-md-3">
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<label for="designated_premises">Designated Premises</label>
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<input type="text" class="form-control" id="designated_premises" name="designated_premises"
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value="<?= isset($lead_edit_data['designated_premises']) ? htmlspecialchars($lead_edit_data['designated_premises']) : ''; ?>">
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</div>
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<!-- Communication Address -->
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<div class="form-group col-md-3">
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<label for="pinCode">Pin Code</label>
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<input type="text" class="form-control" id="pinCode" name="pincode" value="<?= isset($lead_edit_data['pincode']) ? htmlspecialchars($lead_edit_data['pincode']) : ''; ?>">
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</div>
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<div class="form-group col-md-3">
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<label for="address">Communication Address</label>
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<textarea class="form-control" id="address" name="address" rows="1"><?= isset($lead_edit_data['address']) ? htmlspecialchars($lead_edit_data['address']) : ''; ?></textarea>
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</div>
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</div>
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