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