186 lines
12 KiB
PHP
186 lines
12 KiB
PHP
<?php $increment = isset($lead_edit_data) ? "_1" : ''; ?>
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<hr>
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<div class="form-row renewalCalculation">
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<div class="form-group col-md-3 renewalFields" style="display: none;">
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<label for="incurred_claim_date">Incurred Claim Date<span class="text-danger"></span></label>
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<input value="<?= isset($lead_edit_data['incurred_claims_date']) ? $lead_edit_data['incurred_claims_date'] : '' ?>" type="text" class="form-control incurred_claim" id="incurred_claim_date<?= $increment ?>"
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name="incurred_claim_date[]" placeholder="Enter DOE">
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</div>
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<div class="form-group col-md-3 renewalFields" style="display: none;">
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<label for="paid_claims">Paid Claims<span class="text-danger">*</span></label>
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<input value="<?= isset($lead_edit_data['paid_claims']) ? $lead_edit_data['paid_claims'] : '' ?>" type="text" class="form-control" id="paid_claims<?= $increment ?>" name="paid_claims[]"
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placeholder="Enter Paid Claims" oninput="incurredClaimSum(this)">
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</div>
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<div class="form-group col-md-3 renewalFields" style="display: none;">
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<label for="outstanding_claims">Outstanding Claims<span class="text-danger">*</span></label>
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<input value="<?= isset($lead_edit_data['outstanding_claims']) ? $lead_edit_data['outstanding_claims'] : '' ?>" type="text" class="form-control" id="outstanding_claims<?= $increment ?>" name="outstanding_claims[]"
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placeholder="Enter Outstanding Claims" oninput="incurredClaimSum(this)">
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</div>
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<div class="form-group col-md-3 renewalFields" style="display: none;">
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<label for="incurred_claims">Incurred Claim<span class="text-danger">*</span></label>
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<input value="<?= isset($lead_edit_data['incurred_claims']) ? $lead_edit_data['incurred_claims'] : '' ?>" type="text" class="form-control" id="incurred_claims<?= $increment ?>" name="incurred_claims[]"
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placeholder="Enter Incurred Claim" oninput="incurredClaimSum(this)">
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</div>
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<div class="form-group col-md-3 renewalFields" style="display: none;">
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<label for="policy_run_days">Policy Run Days<span class="text-danger">*</span></label>
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<input value="<?= isset($lead_edit_data['policy_run_days']) ? $lead_edit_data['policy_run_days'] : '' ?>" type="text" class="form-control" id="policy_run_days<?= $increment ?>" name="policy_run_days[]"
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placeholder="Enter Policy Run Days" oninput="earnedPremiumCalc(this)" onkeyup="incurredClaimSum(this)">
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</div>
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<div class="form-group col-md-3 renewalFields" style="display: none;">
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<label for="premium_at_inception">Premium Paid at Inception<span
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class="text-danger">*</span></label>
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<input value="<?= isset($lead_edit_data['premium_at_inception']) ? $lead_edit_data['premium_at_inception'] : '' ?>" type="text" class="form-control" id="premium_at_inception<?= $increment ?>" name="premium_at_inception[]"
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placeholder="Enter Premium Paid" oninput="earnedPremiumCalc(this)">
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</div>
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<div class="form-group col-md-3 renewalFields" style="display: none;">
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<label for="premium_date">Premium as on Date<span class="text-danger">*</span></label>
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<input value="<?= isset($lead_edit_data['premium_date']) ? $lead_edit_data['premium_date'] : '' ?>" type="text" class="form-control" id="premium_date<?= $increment ?>" name="premium_date[]"
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placeholder="Enter Premium Date">
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</div>
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<div class="form-group col-md-3 renewalFields" style="display: none;">
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<label for="earned_premium">Earned Premium<span class="text-danger">*</span></label>
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<input value="<?= isset($lead_edit_data['earned_premium']) ? $lead_edit_data['earned_premium'] : '' ?>" type="text" class="form-control" id="earned_premium<?= $increment ?>" name="earned_premium[]"
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placeholder="Enter Earned Premium" oninput="incurredClaimSum(this)">
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</div>
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<div class="form-group col-md-3 renewalFields" style="display: none;">
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<label for="annualised_claims">Annualised Claims<span class="text-danger">*</span></label>
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<input value="<?= isset($lead_edit_data['annualised_claims']) ? $lead_edit_data['annualised_claims'] : '' ?>" type="text" class="form-control" id="annualised_claims<?= $increment ?>" name="annualised_claims[]"
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placeholder="Enter Annualised Claims">
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</div>
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<div class="form-group col-md-3 renewalFields" style="display: none;">
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<label for="incurred_claims_ratio">Incurred Claims Ratio<span
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class="text-danger">*</span></label>
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<input value="<?= isset($lead_edit_data['incurred_claims_ratio']) ? $lead_edit_data['incurred_claims_ratio'] : '' ?>" type="text" class="form-control" id="incurred_claims_ratio<?= $increment ?>"
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name="incurred_claims_ratio[]" placeholder="Enter Incurred Claims Ratio">
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</div>
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<div class="form-group col-md-3 renewalFields" style="display: none;">
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<label for="earned_claims_ratio">Earned Claims Ratio<span class="text-danger">*</span></label>
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<input value="<?= isset($lead_edit_data['earned_claims_ratio']) ? $lead_edit_data['earned_claims_ratio'] : '' ?>" type="text" class="form-control" id="earned_claims_ratio<?= $increment ?>" name="earned_claims_ratio[]"
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placeholder="Enter Earned Claims Ratio">
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</div>
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<!-- <div class="form-group col-md-3 renewalFields" style="display: none;">
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<label for="location">Location <span class="text-danger">*</span></label>
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<input value="<?php //echo isset($lead_edit_data['location']) ? $lead_edit_data['location'] : '' ?>" type="text" class="form-control" id="location" name="location[]" placeholder="Enter Location">
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</div> -->
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<div class="form-group col-md-3 proposed_div" style="display: none;">
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<label for="proposed_insurer">Proposed Insurer <span class="text-danger"></span></label>
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<select class="form-control" id="proposed_insurer" name="proposed_insurer[]">
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<option value="">Select Insurer</option>
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<?php
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if (isset($insurer) && count($insurer)) {
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foreach ($insurer as $key => $value) {
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$selected = (isset($lead_edit_data) && $lead_edit_data['proposed_insurer_branch_id'] == $value['id'] && $lead_edit_data['proposed_insurer_id'] == $value['insurer_id']) ? 'selected' : '';
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echo "<option value=" . $value['id'] . '-' . $value['insurer_id'] . " $selected >" . $value['insurer_name'] . '-' . $value['branch_code'] . "</option>";
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}
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}
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?>
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</select>
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</div>
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<div class="form-group col-md-3 proposed_div" style="display: none;">
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<label for="proposed_tpa">Proposed TPA <span class="text-danger"></span></label>
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<select class="form-control" id="proposed_tpa" name="proposed_tpa[]">
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<option value="">Select TPA</option>
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<?php
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if (isset($tpa) && count($tpa)) {
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foreach ($tpa as $key => $value) {
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$selected = (isset($lead_edit_data) && $lead_edit_data['proposed_tpa_branch_id'] == $value['id'] && $lead_edit_data['proposed_tpa_id'] == $value['tpa_id']) ? 'selected' : '';
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echo "<option value=" . $value['id'] . '-' . $value['tpa_id'] . " $selected >" . $value['tpa_short_name'] . '-' . $value['branch_code'] . "</option>";
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}
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}
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?>
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</select>
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</div>
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</div>
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<hr>
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<div class="form-row">
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<div class="form-group col-md-3">
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<label for="incept_emp_count" class="emp_title"> No of Employees at Inception <span
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class="text-danger">*</span></label>
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<input value="<?= isset($lead_edit_data['incept_emp_count']) ? $lead_edit_data['incept_emp_count'] : '' ?>" type="text" class="form-control" id="incept_emp_count" name="incept_emp_count[]"
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placeholder="Enter Lives" required oninput="calculateTotalLives(this)">
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</div>
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<div class="form-group col-md-3">
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<label for="incept_dept_count" class="depnd_title"> No of Dependents at Inception <span
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class="text-danger">*</span></label>
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<input value="<?= isset($lead_edit_data['incept_dept_count']) ? $lead_edit_data['incept_dept_count'] : '' ?>" type="text" class="form-control" id="incept_dept_count" name="incept_dept_count[]"
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placeholder="Enter Lives" required oninput="calculateTotalLives(this)">
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</div>
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<div class="form-group col-md-3">
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<label for="incept_no_of_lives" class="total_title"> Total Lives at Inception <span
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class="text-danger">*</span></label>
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<input value="<?= isset($lead_edit_data['incept_no_of_lives']) ? $lead_edit_data['incept_no_of_lives'] : '' ?>" type="text" class="form-control" id="incept_no_of_lives" name="incept_no_of_lives[]"
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placeholder="Enter Lives" required>
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</div>
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</div>
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<div class="form-row">
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<div class="form-group col-md-3 renewalFields" style="display: none;">
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<label for="renewal_emp_count"> No of Employees at Renewal <span
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class="text-danger">*</span></label>
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<input value="<?= isset($lead_edit_data['renewal_emp_count']) ? $lead_edit_data['renewal_emp_count'] : '' ?>" type="text" class="form-control" id="renewal_emp_count" name="renewal_emp_count[]"
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placeholder="Enter Lives">
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</div>
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<div class="form-group col-md-3 renewalFields" style="display: none;">
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<label for="renewal_dept_count"> No of Dependents at Renewal <span
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class="text-danger">*</span></label>
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<input value="<?= isset($lead_edit_data['renewal_dept_count']) ? $lead_edit_data['renewal_dept_count'] : '' ?>" type="text" class="form-control" id="renewal_dept_count" name="renewal_dept_count[]"
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placeholder="Enter Lives">
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</div>
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<div class="form-group col-md-3 renewalFields" style="display: none;">
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<label for="renewal_no_of_lives"> Total Lives at Renewal <span
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class="text-danger">*</span></label>
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<input value="<?= isset($lead_edit_data['renewal_no_of_lives']) ? $lead_edit_data['renewal_no_of_lives'] : '' ?>" type="text" class="form-control" id="renewal_no_of_lives" name="renewal_no_of_lives[]"
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placeholder="Enter Lives">
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</div>
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</div>
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<div class="form-row">
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<div class="form-group col-md-3 renewalFields" style="display: none;">
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<label for="exp_emp_count"> No of Employees at Expiry <span class="text-danger">*</span></label>
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<input value="<?= isset($lead_edit_data['exp_emp_count']) ? $lead_edit_data['exp_emp_count'] : '' ?>" type="text" class="form-control" id="exp_emp_count" name="exp_emp_count[]"
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placeholder="Enter Lives">
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</div>
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<div class="form-group col-md-3 renewalFields" style="display: none;">
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<label for="exp_dept_count"> No of Dependents at Expiry <span
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class="text-danger">*</span></label>
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<input value="<?= isset($lead_edit_data['exp_dept_count']) ? $lead_edit_data['exp_dept_count'] : '' ?>" type="text" class="form-control" id="exp_dept_count" name="exp_dept_count[]"
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placeholder="Enter Lives">
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</div>
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<div class="form-group col-md-3 renewalFields" style="display: none;">
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<label for="exp_no_of_lives"> Total Lives at Expiry <span class="text-danger">*</span></label>
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<input value="<?= isset($lead_edit_data['exp_no_of_lives']) ? $lead_edit_data['exp_no_of_lives'] : '' ?>" type="text" class="form-control" id="exp_no_of_lives" name="exp_no_of_lives[]"
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placeholder="Enter Lives">
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</div>
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</div>
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