27 lines
1.4 KiB
PHP
27 lines
1.4 KiB
PHP
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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" value="<?= isset($lead_edit_data['business_activity']) ? htmlspecialchars($lead_edit_data['business_activity']) : ''; ?>">
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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" value="<?= isset($lead_edit_data['limit_of_indemnity']) ? htmlspecialchars($lead_edit_data['limit_of_indemnity']) : ''; ?>">
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</div>
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<!-- Address of the Insured -->
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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">Address of the Insured</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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