63 lines
4.0 KiB
PHP
63 lines
4.0 KiB
PHP
<?php if(isset($lead_edit_data)) {
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$claims = !empty($lead_edit_data['fin_years_claims_array']) ? $lead_edit_data['fin_years_claims_array'] : [ ['year' => '', 'claim_amount' => '', 'status' => '', 'claim_type' => '', 'cause_of_death' => '', 'death_date' => ''] ];
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?>
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<div class="custom-control custom-switch">
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<input type="checkbox" onchange="claimHistoryToggle()" class="custom-control-input" id="claim_history" name="claim_history" <?= $lead_edit_data['claim_history'] == 1 ? "checked" : "" ?> />
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<label class="custom-control-label" for="claim_history">Claims History</label>
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</div><br>
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<?php
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if ($lead_edit_data['claim_history'] == 1) {
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foreach ($claims as $key => $value) { ?>
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<div class="row claim-row">
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<div class="form-group col-md-2">
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<label for="first_year">Year<span class="text-danger">*</span></label>
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<select class="form-control first_year_" id="first_year" name="first_year[]">
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<option value="">Select Year</option>
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<?php foreach ($lastFiveYears as $year) {
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$selected = ($year == $value['year']) ? 'selected' : '';
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echo "<option value='$year' $selected>$year</option>";
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} ?>
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</select>
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</div>
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<div class="form-group col-md-2">
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<label for="first_policy_type_${increment}">Policy Type<span class="text-danger">*</span></label>
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<input type="text" class="form-control" id="first_policy_type_${increment}" name="first_policy_type_[]"
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value="<?= htmlspecialchars($value['policy_type']) ?>">
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</div>
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<div class="form-group col-md-2">
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<label for="first_date_of_loss_${increment}">Date of Loss<span class="text-danger">*</span></label>
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<input type="text" class="form-control loss_date" id="first_date_of_loss_${increment}" name="first_date_of_loss_[]"
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value="<?= htmlspecialchars($value['date_of_loss']) ?>">
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</div>
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<div class="form-group col-md-2">
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<label for="first_cause_of_death_${increment}">Cause Of Loss <span class="text-danger">*</span></label>
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<input type="text" class="form-control" id="first_cause_of_loss_${increment}" name="first_cause_of_loss[]"
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value="<?= htmlspecialchars($value['cause_of_loss']) ?>">
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</div>
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<div class="form-group col-md-2">
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<label for="first_claim_amount_${increment}">Claim Amount<span class="text-danger">*</span></label>
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<input type="text" class="form-control" id="first_claim_amount_${increment}" name="first_claim_amount[]"
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value="<?= htmlspecialchars($value['claim_amount']) ?>">
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</div>
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<div class="form-group col-md-2">
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<label for="first_claim_amount_${increment}">Settled Amount<span class="text-danger">*</span></label>
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<input type="text" class="form-control" id="first_settled_amount_${increment}" name="first_settled_amount[]"
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value="<?= htmlspecialchars($value['settled_amount']) ?>">
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</div>
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<div class="form-group col-md-2">
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<label for="first_claim_status_${increment}">Claim Status<span class="text-danger">*</span></label>
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<input type="text" class="form-control" id="first_claim_status_${increment}" name="first_claim_status[]"
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value="<?= htmlspecialchars($value['status']) ?>">
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</div>
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<div class="form-group col-md-2">
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<div class="" style="position: relative; top: 28px; float: right; text-align: end;">
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<a class="btn btn-danger waves-effect waves-light" onclick="removeClaim(this)">x</a>
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<a class="btn btn-primary waves-effect waves-light mr-1" onclick="appendThreeYearsClaims()">+</a>
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</div>
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</div>
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</div>
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<?php } } ?>
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<?php } ?>
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