80 lines
4.2 KiB
PHP
80 lines
4.2 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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<?php
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$risk_location = isset($lead_edit_data['risk_location']) ? $lead_edit_data['risk_location'] : '';
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?>
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<div class="form-check form-check-inline">
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<input class="form-check-input" type="radio" id="single" name="risk_location" value="Single" <?= ($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" <?= ($risk_location == 'multi_with_floter') ? 'checked' : ''; ?>>
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<label class="form-check-label" for="multi_floater">Multi with Floter</label>
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</div>
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<div class="form-check form-check-inline">
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<input class="form-check-input" type="radio" id="multi_no_floater" name="risk_location" value="multi_without_floter" <?= ($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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<!-- Policy Period -->
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<div class="form-group col-md-3">
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<label for="policy_period">Policy Period</label>
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<select class="form-control" id="policy_period" name="policy_period">
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<?php
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$selected_period = isset($lead_edit_data['policy_period']) ? $lead_edit_data['policy_period'] : '';
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for ($i = 1; $i <= 24; $i++) :
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?>
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<option value="<?= $i ?>" <?= ($selected_period == $i) ? 'selected' : ''; ?>><?= $i ?> Month</option>
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<?php endfor; ?>
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</select>
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</div>
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<!-- Estimated Annual Turnover -->
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<div class="form-group col-md-3">
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<label for="estimated_turnover">Estimated Annual Turnover</label>
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<input type="text" class="form-control" id="estimated_turnover" name="estimated_turnover" value="<?= isset($lead_edit_data['estimated_turnover']) ? htmlspecialchars($lead_edit_data['estimated_turnover']) : ''; ?>">
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</div>
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<!-- Single Carrying Limit -->
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<div class="form-group col-md-3">
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<label for="single_carrying_limit">Single Carrying Limit</label>
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<input type="text" class="form-control" id="single_carrying_limit" name="single_carrying_limit" value="<?= isset($lead_edit_data['single_carrying_limit']) ? htmlspecialchars($lead_edit_data['single_carrying_limit']) : ''; ?>">
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</div>
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<!-- Cash in Safe -->
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<div class="form-group col-md-3">
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<label for="cash_in_safe">Cash in Safe</label>
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<input type="text" class="form-control" id="cash_in_safe" name="cash_in_safe" value="<?= isset($lead_edit_data['cash_in_safe']) ? htmlspecialchars($lead_edit_data['cash_in_safe']) : ''; ?>">
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</div>
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<!-- Cash in TILL -->
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<div class="form-group col-md-3">
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<label for="cash_in_till">Cash in TILL</label>
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<input type="text" class="form-control" id="cash_in_till" name="cash_in_till" value="<?= isset($lead_edit_data['cash_in_till']) ? htmlspecialchars($lead_edit_data['cash_in_till']) : ''; ?>">
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</div>
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<!-- Description -->
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<div class="form-group col-md-3">
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<label for="description">Description</label>
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<textarea class="form-control" id="description" name="description" rows="1"><?= isset($lead_edit_data['description']) ? htmlspecialchars($lead_edit_data['description']) : ''; ?></textarea>
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</div>
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<!-- Communication Address -->
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<div class="form-group col-md-3">
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<label for="pinCode">Pin Code</label>
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<input type="text" class="form-control" id="pinCode" name="pincode" value="<?= isset($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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